Skin cancer referrals by nonmedical practitioners: a prospective observational study.

The aim of this study was to investigate the appropriateness of suspected skin cancer referrals made by nonmedical practitioners (NMPs) and compare this with referrals made by local general practitioners (GPs). Data were collected prospectively from patients referred from primary care to a UK hospital dermatology department. The profession of the referrer was ascertained from review of referral letters and direct questioning. Patient records and subsequent histology reports were reviewed to determine the ultimate diagnoses. Eighty-nine per cent of patients (n = 668/753) were referred by GPs vs. 11.3% (n = 85/753) by NMPs. Fifty-one per cent of patients (n = 340/668) in the GP group and 55% (n = 47/85) in the NMP group were discharged without intervention (P = 0.45). An ultimate diagnosis of skin malignancy was made in 196 of 668 (29.3%) patients in the GP and 25 of 85 (29%) patients in the NMP group (P = 0.99). These early data suggest significant potential for NMPs to become more involved in skin lesion assessment.

Changes in superior mesenteric artery blood flow after oral, enteral, and parenteral feeding in humans.

OBJECTIVE: Alterations in splanchnic blood flow cause gut ischemia and may predispose to gut-derived sepsis. Increases in superior mesenteric artery (SMA) blood flow occur follow the oral ingestion of food, but the effects of enteral nutrition (EN) on splanchnic perfusion are poorly defined and those of parenteral nutrition (PN) are unknown in humans. The aim of this study was to investigate changes in SMA flow in healthy controls and patients receiving adjuvant nutrition. DESIGN: Qualitative before-after study. SETTING: Intensive care and general wards at Scarborough Hospital, Scarborough, United Kingdom. PATIENTS: Fourteen healthy volunteers and 20 consecutive hemodynamically stable patients receiving adjuvant nutrition. INTERVENTIONS: Oral, EN, or PN after an overnight fast. MEASUREMENTS AND MAIN RESULTS: Duplex ultrasonography was used to assess SMA flow after an overnight fast. Subjects were then rescanned 3 hrs later after commencement of the appropriate test feed so that postprandial flows could be determined. Of the 20 patients recruited, 10 were receiving EN (120 kcal) and 10 PN (175 kcal). Of the 14 volunteers, three received no feed before their second scan (controls), six received an oral meal (530 kcal), and five received EN (120 kcal). Changes in SMA flow within groups were assessed. The control (fasting) volunteers showed no change between the two scans (p = 1.000). All subjects fed intraluminally demonstrated significant increases in postprandial SMA blood flow. Conversely, all patients fed parenterally showed decreased postprandial SMA flows with a median (interquartile range) fasting SMA flow of 14.5 (4.8-24.8) mL/sec, which decreased to 6.1 (2.4-9.2) mL/sec postprandially (p = 0.013). CONCLUSIONS: Splanchnic flow is modulated by the route of feeding. The clinical significance of these findings requires further investigation as they may be important in the management of the critically ill patient, particularly in those with cardiovascular instability or any patient predisposed to gut ischemia.

A prospective randomised trial of probiotics in critically ill patients.

BACKGROUND AND AIMS: Probiotics exert a beneficial effect on the host through modulation of gastrointestinal microflora. The aim of this study was to investigate the effect of the probiotic Lactobacillus plantarum 299v on gut barrier function and the systemic inflammatory response in critically ill patients. SUBJECTS AND METHODS: One hundred and three critically ill patients were randomised to receive an oral preparation containing L. plantarum 299v (ProViva) in addition to conventional therapy (treatment group, n = 52) or conventional therapy alone (control group, n = 51). Serial outcome measures included gastric colonisation, intestinal permeability (lactulose/rhamnose dual-sugar probe technique), endotoxin exposure (IgM EndoCAb), C-reactive protein and Interleukin 6 levels. RESULTS: L. plantarum had no identifiable effect on gastric colonisation, intestinal permeability, endotoxin exposure or serum CRP levels. There were no differences between the groups in terms of septic morbidity or mortality. On day 15 serum IL-6 levels were significantly lower in the treatment group compared to controls. CONCLUSIONS: The enteral administration of L. plantarum 299v to critically ill patients was associated with a late attenuation of the systemic inflammatory response. This was not accompanied by any significant changes in the intestinal microflora, intestinal permeability, endotoxin exposure, septic morbidity or mortality.

Influence of synbiotic containing Lactobacillus acidophilus La5, Bifidobacterium lactis Bb 12, Streptococcus thermophilus, Lactobacillus bulgaricus and oligofructose on gut barrier function and sepsis in critically ill patients: a randomised controlled trial.

BACKGROUND & AIMS: Infective complications are a common cause of mortality and morbidity in critically ill patients. Many factors affect sepsis, one of which is gut barrier function. The aim of this study was to determine whether the oral administration of a synbiotic preparation could alter gut barrier function in critically ill patients and thus reduce sepsis. METHODS: A total of 90 patients admitted to an intensive care unit (ICU) were randomised to receive either synbiotic or placebo preparations (45 into each group). The synbiotic preparation consisted of Lactobacillus acidophilus La5, Bifidobacterium lactis Bb 12, Streptococcus thermophilus and Lactobacillus bulgaricus (probiotics) with oligofructose (prebiotic). Gut barrier function was assessed by measurement of intestinal permeability (lactulose/rhamnose test) and culture of nasogastric aspirate on days 1 and 8. All septic complications and mortality were recorded. RESULTS: There were no differences between the groups in terms of age, sex, APACHE II or POSSUM scores. After 1 week of therapy, patients in the synbiotic group had a significantly lower incidence of potentially pathogenic bacteria (43% versus 75%, P = 0.05) and multiple organisms (39% versus 75%, P = 0.01) in their nasogastric aspirates than controls. There were no significant differences between the groups in terms of intestinal permeability, septic complications or mortality. CONCLUSIONS: The administration of synbiotic in critically ill patients favourably altered the microbial composition of the upper gastrointestinal tract but had no effect on intestinal permeability and was not associated with measurable clinical benefit.