Peripheral intravenous nutrition.
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Female↗
Biomedical subjects
M J McMahon
Publications and source records attributed to M J McMahon.
Influence of catheter type on occurrence of thrombophlebitis during peripheral intravenous nutrition.
To reduce the likelihood of thrombophlebitis during intravenous feeding through a peripheral vein, the osmolality of the solution is usually reduced by disproportionately raising the lipid content and lowering the carbohydrate, electrolyte, and aminoacid concentrations. The possibility that delivery system rather than feed is the main influence on the development of thrombophlebitis was examined in a randomised comparison of a fine-bore silicone catheter against a short 'Teflon' cannula. The nutrient solution given through a peripheral vein was a standard feed used for infusion into a central vein (osmolality 1250 mOsmol/kg, 13 g nitrogen, 200 g glucose [800 kcal], and lipid emulsion [1000 kcal]). 27 patients received the infusion through a fine-bore silicone rubber catheter (diameter 23 G, length 15 cm) and 23 through a teflon catheter (diameter 20 G, length 3.2 cm). The median duration of feeding was 5 days in each of the two groups. Thrombophlebitis developed in all patients in the teflon group but in only 2 (7%) of the silicone group. The first silicone catheter for a patient lasted a median of 128.5 h, compared with 40 h for the first teflon cannula (p less than 0.001). The results show that when a nutrient solution of osmolality 1250 mOsmol/kg is delivered through a peripheral vein with an ultrafine-bore silicone catheter, the risk of thrombophlebitis is low. For many patients intravenous feeding may thus be given through a peripheral instead of a central vein without compromising the nutritional adequacy of the feed.
Adolescent↗
Thoracoscopic enucleation of leiomyoma of the oesophagus.
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Esophageal Neoplasms↗
Laparoscopic cholecystectomy as a routine procedure for gallstones: results of an 'all-comers' policy.
A total of 165 consecutive patients with gallstones were considered for laparoscopic cholecystectomy. Three were excluded. The median age was 52 years and 76 per cent were women. Eighteen patients underwent urgent operation. Laparoscopic cholecystectomy was successful in 160 of the 162 patients (99 per cent). The two failures were the result of dense adhesions and stones in the bile duct. There were no deaths but major complications occurred in three patients: fenestration of the colon sutured laparoscopically; bleeding from a cannulation site and subsequent laparotomy for a strangulated hernia; and subphrenic abscess. There were 13 minor complications, but no bile duct injuries or peritonitis. The median postoperative hospital stay was 1 day. Bile duct stones were present in 14 patients (9 per cent) and were removed by endoscopic sphincterotomy (11 patients), by laparoscopic exploration of the common duct (two) and by conversion to laparotomy (one). These results suggest that laparoscopic cholecystectomy is applicable to the large majority of patients who require elective or urgent cholecystectomy, if appropriate radiological and endoscopic support is available.
Adolescent↗
Classical oestrogen receptor is not detectable in pancreatic adenocarcinoma.
Recent reports have suggested the presence of oestrogen receptors (ER) in pancreatic carcinoma. Therefore the tumour may be sensitive to hormone manipulation therapy. We examined 23 biopsies of human pancreatic carcinoma tissue for the presence of ER. The tissue was assayed by two methods: Iso-electric focusing (IEF) and ER-ICA an immunocytochemical assay. All biopsies were tested with ER-ICA and ten by IEF. Each biopsy was assessed histologically for tumour content and 20 contained adenocarcinoma. None of the samples of pancreatic carcinoma were positive for ER using the ER-ICA, and none demonstrated the binding peak typical of ER in the IEF assay. These results suggest that in pancreatic carcinoma oestrogen receptor is either absent (or at very low levels), or of a different type to that found in breast and uterine tissue. On theoretical grounds at least, this must raise questions as to the oestrogen sensitivity of pancreatic cancer.
Adenocarcinoma↗
Evidence for the indirect utilization of glucose for the synthesis of hepatic glycogen in man.
1. This study was designed to test the hypothesis that three-carbon intermediates can be used in the 'indirect' pathway of glycogen synthesis in human liver (i.e. a route additional to the use of glucose by the 'direct' pathway). 2. After an overnight fast, 13 patients were given an infusion of 20% (w/v) glucose before elective abdominal operation. All received a 2.5 g bolus of 2220 kBq of selectively 3H- and 14C-labelled glucose before removal of a 1 g biopsy of liver. 3H and 14C were determined in purified glycogen as well as in glucose and lactate from samples of peripheral blood. 3. The ratio and specific activities of 3H and 14C in glycogen were found to be significantly lower than those in administered glucose. By calculation, 7-74% of glycogen repletion occurred by indirect pathways and not all of this was from the glucose supplied. 4. This study suggests that the operation of a direct pathway in man is not exclusive and that significant repletion of hepatic glycogen occurs by an indirect route.
Adult↗
Open versus laparoscopic cholecystectomy: a retrospective comparative study.
Two groups of 40 patients (31 females, 9 males), matched for age and body mass index, who underwent either elective open cholecystectomy (Group I) or elective laparoscopic cholecystectomy (Group II) have been studied retrospectively to detect differences in operating time, morbidity and mortality, hospital length of stay, and use of postoperative analgesics. The two groups of patients had almost identical histories of gallstone disease. The median operating time for the patients in Group I was 45 min (range 35-95) compared with 90 min (range 50-135) in Group II. An intraoperative cholangiogram was performed in 21 of the patients in Group I and 22 patients in Group II. There were no deaths in either group. The overall complication rate was 22.5% in Group I and 10% in Group II. Median postoperative length of stay was 5 days for Group I patients (range 1-19) and 2 days for Group II patients (range 1-5). All Group I patients required postoperative intravenous or intramuscular opiates, while 10% of Group II patients did not require any analgesia at all and pain was controlled with oral analgesics alone in 16%. Median total morphine dose for Group I patients was 46.9 mg (range 9.4-180), as compared with only 15.6 mg (6.2-37.5) for Group II patients. This study concludes that laparoscopic cholecystectomy led to less complications, shorter hospital length of stay, and minimal use of postoperative analgesia.
Analgesics, Opioid↗
Treatment of acute pancreatitis caused by calculous obstruction of the pancreatic duct by ultrasound-guided percutaneous drainage.
In a small percentage of patients with acute pancreatitis, recurrent attacks of pain and hyperamylasaemia occur when feeding is commenced. Recurrences of this type may occur because the pancreas is still swollen and inflamed, and indicate the need for a longer period of "pancreatic rest" before food is introduced. Alternatively, they may reflect the presence of "mechanical" factors leading to the recurrent pancreatitis, such as a gallstone in the common bile duct, a pseudocyst of the pancreas, or pancreatic duct obstruction. Successful resolution of the pancreatitis may require treatment of underlying causative factors. A stone in the pancreatic duct (probably a gallstone) was found to be the cause of recurrent acute pancreatitis in an elderly patient with severe cardiovascular disease, who was unfit for surgery. Pancreatitis settled after percutaneous drainage of the pancreatic duct, the technique described.
Acute Disease↗
Early gastric cancer: 46 cases treated in one surgical department.
Forty six consecutive patients with early gastric cancer were treated between 1970 and 1990. The proportion of cases of early gastric cancer increased significantly (p < 0.01) from 1% of all cases in the first five year period to 15% in the last five year period, because of greater awareness of the condition and more widespread use of endoscopy. There were 33 men and 13 women, of median age 69 years (range 38-86). Most patients (91%) presented with symptoms indistinguishable from those of peptic ulceration. The median duration of symptoms was four months (range 0.1-36 months). All 46 patients were treated surgically. Three patients (6.5%) died after operation and a further 10 (22%) suffered postoperative complications. None of the surviving patients has been lost to follow up and 25 have been followed up for a minimum period of five years. Five year survival by life table analysis was 98%. These findings suggest that in Britain in the 1990s, as in Japan, it may be possible to diagnose an increasing proportion of patients with gastric cancer at a relatively early pathological stage, when most patients can be cured by radical surgical resection with lymphadenectomy.
Adult↗
The prognostic value of the tumour markers CA 195 and CEA in patients with adenocarcinoma of the pancreas.
The serum levels of CA 195 were determined in 52 patients with histologically proven pancreatic carcinoma and compared with carcino-embryonic antigen (CEA), serum bilirubin and albumin. CA 195 levels were raised above the upper limit of 20 U/ml in 42 cases, giving a sensitivity of 80% for the detection of pancreatic carcinoma, whereas CEA was raised in only 55%. The levels of CA 195 and CEA were significantly higher in patients with metastatic disease, but potentially curable cases were not discriminated. Bilirubin and albumin levels were not significantly related to either the presence of metastases or the levels of the tumour markers. At the time of initial presentation, levels of both tumour markers correlated with the eventual duration of survival, but bilirubin and albumin did not. Significant increases in CEA and CA 195 were found in sequential blood samples, as the disease progressed. Neither CA 195 nor CEA was of sufficient sensitivity to be of value for screening, but both give an indication of the presence of metastases and of the subsequent duration of survival. CA 195 appeared to be more sensitive and might help to assess progress of the disease.
Adenocarcinoma↗
Is fatal pancreatitis a consequence of excessive leukocyte stimulation? The role of tumor necrosis factor alpha.
This study examines the possible role of excessive leukocyte stimulation in the pathogenesis of acute pancreatitis. Levels of tumor necrosis factor alpha (TNF-alpha) and elastase-alpha 1 proteinase inhibitor (E-alpha 1PI) have been measured as markers of macrophage and neutrophil activation, respectively, in serial plasma samples from 27 patients with acute pancreatitis. Levels of TNF-alpha did not support the possibility of excessive macrophage activation, but raised levels of E-alpha 1PI in patients with either the mild or severe form of the illness indicated the activation of neutrophils. Whether this is a consequence of the illness or is a contributory factor in the pathogenesis is not clear.
Acute Disease↗
Articular disease severity in rheumatoid subjects with and without Felty's syndrome.
Articular disease severity as measured by a radiographic score of hands and feet was compared in rheumatoid subjects with (21) and without (170) Felty's syndrome. Disease duration was a major determinant of joint destruction. When this was taken into consideration radiographic scores were no higher in the Felty's group than in rheumatoid subjects without Felty's syndrome. Immunogenetic associations previously described in Felty's syndrome are unlikely therefore to represent non-specific markers of disease severity and more likely to represent markers of extra-articular disease.
Arthritis, Rheumatoid↗
Alpha 2 macroglobulin state in acute pancreatitis. Raised values of alpha 2 macroglobulin-protease complexes in severe and mild attacks.
Plasma values of C reactive protein, alpha 1 proteinase inhibitor, alpha 2 macroglobulin, and complexed alpha 2 macroglobulin have been determined in serial samples from 27 patients with acute pancreatitis. Complexed alpha 2 macroglobulin was measured by a novel enzyme linked immunosorbent assay with a monoclonal antibody specific for the complexed form. Patients with severe illness had lower concentrations of total alpha 2 macroglobulin and higher concentrations of complexed alpha 2 macroglobulin than those with mild illness, and in the majority of severe attacks the abnormal amounts of complexed alpha 2 macroglobulin were present throughout the eight days of the study. The proportion of total alpha 2 macroglobulin in the uncomplexed form, however, was generally greater than 90%, and in 26% of the mild cases completely normal concentrations of uncomplexed alpha 2 macroglobulin (greater than 99% of total) were found throughout the eight days of the study. This suggests that exhaustion of alpha 2 macroglobulin in plasma is unlikely to be a major factor in the pathogenesis of acute pancreatitis.
Acute Disease↗
Dynamic contrast enhanced computed tomography: a precise technique for identifying and localising pancreatic necrosis.
OBJECTIVE: To evaluate dynamic contrast enhanced computed tomography for detecting and localising pancreatic necrosis in acute pancreatitis. DESIGN: Prospective evaluation with blind reporting of scans. SETTING: Single teaching hospital. PATIENTS: 60 Consecutive patients with acute pancreatitis suspected to have pancreatic necrosis because of major organ system failure (13); slow recovery five to seven days after admission with raised scores on the acute physiological and chronic health evaluation (APACHE-II) system (27); or findings on previous ultrasonography or computed tomography (20). MAIN OUTCOME MEASURE: Pancreatic necrosis proved histologically--that is, greater than 30 g necrotic tissue debrided at laparotomy (for life threatening sepsis or peritonitis) or necropsy. RESULTS: Dynamic computed tomography correctly localised pancreatic necrosis in 11 patients (confirmed at laparotomy in nine and at necropsy in two). Of nine patients with low enhancement of peripancreatic tissues alone, eight recovered after conservative management; necropsy confirmed viable pancreas and necrosis of peripancreatic fat in one patient. Of 40 patients with normal contrast enhancement, none required laparotomy to debride pancreatic necrosis. CONCLUSION: Dynamic contrast enhanced computed tomography seems to be a safe and accurate method of identifying and localising pancreatic and peripancreatic necrosis, which cannot be predicted accurately by conventional imaging techniques.
Acute Disease↗
Measurement of the 'fast' or complexed form of alpha 2 macroglobulin in biological fluids using a sandwich enzyme immunoassay.
A sandwich enzyme immunoassay has been developed for measuring the 'fast' or complexed form of alpha 2 macroglobulin using a complex-specific monoclonal antibody. The working range of this assay is 1.5-15 micrograms/l and is suitable for use with various biological fluids. Using this assay the normal plasma levels were found to range from 4.2 mg/l to 14.4 mg/l (0.17%-0.70% of total alpha 2 macroglobulin) with a mean value of 7.6 mg/l +/- 2.6 (0.37% +/- 0.12% of total alpha 2 macroglobulin). Elevated levels were seen in plasma samples taken on the day of admission from patients with acute pancreatitis and in some synovial fluid samples from patients with various arthritides.
Antibodies, Monoclonal↗
Proteolytic degradation of human recombinant proinsulin/insulin by sera from acute pancreatitis patients and complete inhibition by Eglin-C.
Sera from patients of biliary, alcoholic, and idiopathic acute pancreatitis with severity scored from 1 to 5 based on the Ranson criteria were tested for proinsulin/insulin degrading activity. Proinsulin degrading activity by normal controls was 8 +/- 4% as compared with 22-78 +/- 17% with a mean of 45% by the patient sera. An order of magnitude increase of proinsulin degrading activity was accompanied by an order of magnitude increase of immunoreactive pancreatic cationic trypsin(ogen) and (pro)elastase-2 as determined by radioimmunoassay with day 1 sera. Proinsulin degrading activity also showed a negative correlation with the clinical time course and dropped to normal by 6 days after admission. The decrease of proinsulin degrading activity was concomitant with a decrease of serum immunoreactive pancreatic serine proteases. High-performance liquid chromatography analysis of the proteolysis products showed the appearance of insulin and smaller peptides with no proinsulin conversion intermediates. Ninety to ninety-eight percent of proinsulin degrading activity was inhibited by anti-alpha 2-macroglobulin (alpha 2-M) antiserum, or (Ac)Eglin-C(J141), and 52% by an elastase and chymotrypsin-specific inhibitor, MeOSuc-Ala-Ala-Pro-boroVal-pinacol. E64c, TLCK, alpha 1-protease inhibitor (alpha 1-PI), or Trasylol inhibited proinsulin degrading activity by 10-17%, and anti-cathepsin B antiserum by 9%. The observed proinsulin degrading activity did not correlate with the Ranson's scores, age, sex, etiology, total serum immunoreactive insulin, calcium, albumin or alpha 2-M but had a negative correlation with serum alpha 1-PI (r = -0.55) and a positive correlation with serum esterase activity (r = .62).(ABSTRACT TRUNCATED AT 250 WORDS)
Humans↗
APACHE-II score for assessment and monitoring of acute pancreatitis.
The value of the Acute Physiology and Chronic Health Enquiry (APACHE-II) score, the Simplified Acute Physiology score, and the Medical Research Council (MRC) sepsis score were compared with clinical assessment and Ranson and Imrie scores in the evaluation and monitoring of acute pancreatitis in 290 attacks. Attacks were graded mild (231) if uncomplicated, or severe (59) when major organ failure or a pancreatic collection occurred. Only APACHE-II scores were available at the time of admission; they correctly predicted outcome in 77% of attacks and identified 63% of severe attacks, compared with 44% achieved by clinical assessment. After 48 h, APACHE-II was most accurate, and correctly predicted outcome in 88% of attacks, compared with 69% for Ranson and 84% for Imrie scores. APACHE-II predicted 73% of pancreatic collections at 48 h, compared with 65% for Ranson and 58% for Imrie scores. In acute pancreatitis, APACHE-II may facilitate rapid selection of patients for intensive therapy or clinical trials, improve comparison between groups of patients, and indicate that a pancreatic collection is probable.
Abscess↗
Use of deep tension sutures and buttress plates for frequent relaparotomy.
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Abscess↗