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Biomedical subjects

M H Irving

Publications and source records attributed to M H Irving.

At least 73 records · Page 4Linked to original sources
PubMed1988

The operative management of fistulous Crohn's disease.

In 100 consecutive patients with fistulous Crohn's disease who were managed surgically during a 12 year period, a 96 per cent closure rate was obtained with only a 1 per cent 30 day mortality rate. En bloc resection of the diseased intestine and fistula with primary anastomosis was the preferred treatment, but temporary exteriorization of the intestinal ends was undertaken in patients compromised by extensive sepsis or profound hypoalbuminemia. In 43 patients, there were 70 secondary intestinal defects caused by the fistula eroding into otherwise healthy intestine. The majority of these defects were successfully closed by primary suture; however, three secondary duodenal defects, treated by primary suture alone, failed to heal and fistulas recurred. As a result, two of these patients died of overwhelming sepsis. Since adopting closure or protection of duodenal defects by a jejunal serosal patch, this problem has not arisen again. One defect in the sigmoid colon treated by primary suture also had recurrence of fistula, probably because the repair lay adjacent to an abscess cavity. Temporary loop colostomy is now used to protect repairs of defects in the sigmoid colon undertaken in the presence of local sepsis.

Adolescent↗
PubMed1987

Does local intestinal ascorbate deficiency predispose to fistula formation in Crohn's disease.

Samples of maximally diseased and adjacent macroscopically normal intestine from 52 patients undergoing surgery for Crohn's disease were analyzed for ascorbate content; 26 of the patients had intestinal fistulas and 26 did not. Ascorbate analyses were also performed on samples of normal intestine from ten control patients. Diseased intestine from both groups of patients with Crohn's disease contained significantly more ascorbate than the adjacent macroscopically normal intestine. Their diseased intestine also contained significantly more ascorbate than normal intestine from controls. Whereas diseased intestine from patients without fistulas contained 47 percent more ascorbate than their normal intestine (P less than .001), the diseased intestine from patients with fistulas contained only 23 percent more ascorbate than their normal intestine (P less than .02). Patients with fistulas appear unable to concentrate as much ascorbate in their diseased intestine as patients without fistulas. This difference may be a factor in the pathogenesis of fistula formation in Crohn's disease because of the importance of ascorbate in collagen production.

Adult↗
PubMed1987

Nutritional management of pregnancy in patients on home parenteral nutrition.

Three pregnancies are reported in two patients on home parenteral nutrition for intestinal failure. The nutritional regimen, 2300 kcal (9.63 MJ) (18% as lipid emulsion), 14 g amino acid nitrogen and electrolytes supplied daily in a 'big bag', was based on the measured resting energy expenditure and urinary nitrogen excretion during the third trimester in a 30-year-old woman on home parenteral nutrition. Commercial preparations of trace elements were added to the infusion as dictated by serum levels. Iron, iodine and fluoride were given orally, and vitamin B12 by monthly intramuscular injection. There were no serious deficiencies in trace elements and maternal weight-gain and fetal growth were satisfactory in all three pregnancies. The two pregnancies in one patient went to term and both infants had birthweights at the 50th centile for gestational age. The second patient who had had two spontaneous abortions went into premature labour at 30 weeks and gave birth to a baby with a minor facial deformity who subsequently developed the idiopathic respiratory distress syndrome. All three placentas were histologically normal. The growth and development of all three babies has been satisfactory. This nutritional regimen should be adequate for most pregnant patients who have attained a normal nutritional status on parenteral nutrition.

Adult↗
PubMed1987

The surgical management of pancreatic abscess.

In the past 6 years we have operated on 13 patients with pancreatic abscess. Sepsis recurred in all 12 in whom the primary procedure was closed drainage. Following further surgical debridement of these recurrent abscesses 2 patients had further closed drainage and in 10 the cavities were packed open to heal by granulation. One patient underwent primary open packing which eliminated the pancreatic abscess but the patient subsequently died. Six patients (46%) died: one of lung abscesses after recovering completely from secondary open packing, one of an unsuspected carcinoma of the pancreas after secondary closed drainage and 4 of multiple organ failure after secondary open packing. There were no residual intraabdominal abscesses in any of these at autopsy. Four of those who died had initially presented with catastrophic pancreatitis according to Ranson's criteria and all 3 patients with initial sepsis scores of greater than or equal to 15 died. Open packing, whilst appearing to provide better drainage of pancreatic abscesses than closed drainage does not have a dramatic influence on mortality. Future reports of the results of open and closed methods of treating pancreatic abscesses should take account of both the severity of pancreatitis and of sepsis.

Abscess↗
PubMed1986

Effects of nutrient intake, surgery, sepsis, and long term administration of steroids on muscle function.

The stimulated contraction-relaxation characteristics of the adductor pollicis muscle were used to assess nutritional state in patients and healthy controls. In both groups insufficient nutrition resulted in abnormal muscle function. The ratio of force of contraction at 10 Hz to that at 20 Hz yielded the best combination of sensitivity (87%) and specificity (82%). Sepsis resulted in abnormal muscle function, but the changes were easily distinguishable from those in subjects taking an inadequate diet. Long term administration of steroids, trauma, and surgery had no effect on muscle function. A prospective study of 11 malnourished patients with abnormal muscle function showed that all variables of muscle function returned to normal values with total parenteral nutrition. This reversal correlated significantly with the duration of parenteral nutrition and occurred before any change in anthropometric variables or plasma albumin concentration. Muscle function studies are sensitive and specific indicators of malnutrition; results depend on energy intake but are not influenced by administration of steroids, trauma, or surgery.

Energy Metabolism↗
PubMed1986

'Laparostomy': a technique for the management of intractable intra-abdominal sepsis.

Following laparotomy for severe intra-abdominal sepsis, the abdominal cavity was left open to heal by granulation in 18 patients. In 14 patients, operation was required because of recurrent gastrointestinal perforation or anastomotic dehiscence. In three, the indication for this procedure was recurrent pancreatic abscess. Of the 17, 13 had previously undergone multiple operations which had failed to control sepsis. Laparostomy was performed as a primary procedure in only one case, a patient with fulminating pancreatitis requiring pancreatic necrosectomy. All patients received parenteral nutrition. The overall mortality was 28 per cent. However, there was only one death among the last 9 patients treated compared with 4 in the previous 9. The median sepsis score in the first 9 (19, range 10-26) was not significantly different (P greater than 0.05) from that in the subsequent 9 patients (17, range 8-21). Three of the four who had initially presented with severe acute pancreatitis died. No patient eviscerated and only 9 (50 per cent) required mechanical ventilation for a median duration of 5 days. The median time for wound healing was 10 weeks and 6 patients have subsequently undergone definitive surgery with satisfactory results. Laparostomy is a valuable technique in the management of severe, intractable intra-abdominal sepsis.

Abdominal Muscles↗
PubMed1986

Essential trace element provision to patients receiving home intravenous nutrition in the United Kingdom.

The methods of provision of essential trace elements to patients receiving long-term home intravenous nutrition in the U.K. have been reviewed and their trace element status has been assessed. Over a 2 year period, 57 patients based on 15 hospitals throughout the country were studied. Although biochemical abnormalities of trace element status were frequent, related clinical complications were apparently rare. Zinc provision from commercial preparations generally required further supplementation. Copper requirements were variable. Manganese provision from trace element mixtures and chromium provision from contaminants of other parenteral nutrient solutions were excessive in many cases. Aluminium contamination is not significant in the nutrient solutions currently used in the U.K. The most common depletion state is for selenium which should probably be provided on a routine basis. The clinical consequences of long-term under- or over-provision of trace elements by the intravenous route requires further study.

Journal Article↗
PubMed1985

Comparison of clinical scores and acute phase proteins in the assessment of acute Crohn's disease.

Fifty-two patients with Crohn's disease have been assessed using acute phase proteins and a scoring system. Thirty-nine underwent operation and intra-abdominal abscesses were found in seventeen. Both scores and acute phase proteins have been shown to reflect inflammation due to secondary sepsis in addition to that from active Crohn's disease. The scores were higher, and acute phase changes greater, in patients with sepsis than those without. By choosing a threshold for each variable that excludes patients without sepsis it has been found that a score greater than 181, ESR greater than 45 mm/h, CRP greater than 33 mg/l, orosomucoid greater than 1.8 g/l and albumin less than 26.7 g/l identify sepsis with a specificity greater than 95 per cent and sensitivity greater than 35 per cent. Over 70 per cent of patients with abscesses exceeded one or more of these thresholds. We believe that operative management should be strongly considered if one or more of these criteria are positive as such patients have a greater than 90 per cent chance of having an intra-abdominal abscess. This will prevent these abscesses eroding into adjacent viscera or to the surface with resulting fistula formation.

Abscess↗
PubMed1984

The significance of changes in blood lymphocyte populations following surgical operations.

After surgery blood lymphocyte levels fell to one-third of the pre-operative value. Since this depression was transient, and followed the peak of serum cortisol closely, it was probably due to a redistribution of lymphocytes from the blood to the tissues. The proportion of activated lymphocytes, as measured by the incorporation of 3H-thymidine in vitro without added mitogen, was substantially increased about 5-8 days after operation. The greatest number of S-phase lymphocytes was found after operation combined with blood transfusion but surgery alone and blood transfusion alone each produced significant increases. The proportions of B lymphocytes, T helper cells and T suppressor cells remained nearly constant despite the fluctuations in total lymphocyte counts. The response of lymphocytes in vitro to phytohaemagglutin (PHA) was doubled on average 7 days after surgery provided the test was performed in the patient's own serum. In pooled serum there was no consistent change in the response to PHA. It is argued that none of the observed changes necessarily signify that a phase of immunosuppression follows surgical operations.

Blood Transfusion↗
PubMed1983

Streptococcus milleri and surgical sepsis.

For many years Viridans streptococci have been considered as commensal organisms in a wide variety of sites in the human body and only regarded as significant pathogens in subacute bacterial endocarditis. However, in recent years some reports have suggested that a particular species, Streptococcus milleri, can be a virulent pathogen, producing life-threatening sepsis particularly in surgical patients. We review here our experience of this organism in 23 general surgical patients over a 3 year period, and postulate that prophylactic use of antibiotic combinations such as gentamicin and metronidazole in patients undergoing colo-rectal surgery may be a factor promoting its emergence as a significant pathogen. Patients with established sepsis due to Streptococcus milleri should be considered for long-term antibiotic therapy as part of the treatment of their abscesses.

Abscess↗
PubMed1982

Intracellular free amino acids in undernourished patients with or without sepsis.

1. Thigh muscle samples for analysis were obtained from 35 control subjects and 12 severely ill patients, of whom five had disease-induced undernutrition and seven had associated sepsis. An improvement in the Bergström technique for analysing muscle needle biopsy samples was used. 2. Muscle water, chloride and DNA were increased in both groups of ill patients, indicating an increase in the extracellular component and loss of muscle protein. 3. Falls in the concentrations of glutamine, glutamate, arginine, histidine, ornithine and lysine and rises in those of glycine, serine, asparagine, tyrosine, valine, leucine, isoleucine, phenylalanine, methionine and tryptophan were observed in the group of ill patients compared with those in the control subjects. The changes were present mainly in the patients with sepsis, significant differences between these and the undernourished ones without associated sepsis being observed in glutamine, lysine, tyrosine, valine, leucine, isoleucine, phenylalanine and methionine. The changes were either absent or slight in plasma. 4. The increased concentrations observed in six essential amino acids in the septic patients, but not in those with undernutrition, is consistent with the increased catabolic rate of sepsis. 5. However, the branched-chain amino acids, and lysine, threonine, arginine, and histidine, were present in lower concentrations than might be expected from catabolism, presumably due to utilization. It is suggested therefore that septic patients might benefit from increased proportions of these amino acids in their feeding regimen.

Adolescent↗
PubMed1980

Parenteral nutrition in Crohn's disease.

A retrospective study of 50 consecutive patients admitted to hospital with Crohn's disease has been undertaken in order to assess the place of parenteral nutrition in our management of this disease. Following treatment, median weight, hemoglobin, and plasma albumin were the same in three treatment groups--parenteral nutrition (12), low-residue diet (9), and normal diet (29). Of 13 courses of parenteral nutrition used in 12 patients, 10 were for periods of less than 14 days (median four days). Most patients with nutritional problems associated with Crohn's disease can be treated successfully by one or other form of enteral nutrition. Parenteral nutrition, if required, is usually only necessary for periods of less than two weeks, to support patients over a critical period in their illness. Occasionally prolonged parenteral nutrition is required for short-bowel syndrome or advanced fistulous disease. In these cases, training the patient to infuse himself with nutrients at home has much to recommend it.

Adolescent↗
PubMed1980

N tau-Methylhistidine excretion and myofibrillar protein breakdown in patients receiving intravenous or enteral nutrition.

1. N tau-Methylhistidine, nitrogen and creatinine were measured in the urine of 10 volunteers on normal and meat-free diets and in 10 vegetarians, and compared with the results from the urine of eight patients with intestine fistulae on intravenous or enteral nutrition containing no meat. The values obtained were used to calculate fractional breakdown rate of myofibrillar protein. 2. There was a significant fall in the excretion of N tau-methylhistidine and creatinine and in apparent fractional breakdown rates after 2 days on a meat-free diet. 3. One of the patients had lower, and two of the patients had higher, fractional breakdown rates compared with the vegetarians. 4. N tau-Methylhistidine and creatinine excretion may be a useful and non-invasive measurement of myofibrillar protein degradation in patients on meat-free diets. Firm conclusions cannot, however, be drawn without confirmatory, direct measurement of the breakdown rates of muscle protein in vivo.

Adult↗