Horacio Rilo

Pancreas vs. islet transplantation: a call on the future.

Purpose of reviewThe aim of this article is to review recent reports on whole pancreas and islet cell transplantation. It focuses on ‘what the call to the future looks like’ for both therapies as treatment options for those type 1 diabetes patients who do not respond well to conventional therapy. Recent findingsThe major benefit of pancreas transplantation is the reversal of diabetes improvement of diabetes complications. Although the procedure requires major surgery and life-long immunosuppression, it remains the gold standard for a specific population of patients who suffer from type 1 diabetes and who do not respond to conventional therapy. Allogeneic islet transplantation is a promising alternative to pancreas transplantation, but patient outcomes remain less than optimal and significant progress is required in order for this procedure to be considered a reliable therapy. ConclusionSeveral factors have to be taken into consideration before making the decision of which of these procedures would better suit a patient with type 1 diabetes.

Novel Technique of Total Pancreatectomy Before Autologous Islet Transplants in Chronic Pancreatitis Patients

i d c v c a l s U t t Chronic pancreatitis is a disease characterized by progressive destruction of the pancreatic exocrine tissue, leading to fibrosis and calcification of the pancreas. Patients develop severe and debilitating chronic abdominal pain and have an extremely poor quality of life. Pain is a major cause of morbidity, but exocrine and endocrine insufficiency is severe as well. Chronic pancreatitis may be a sequela of acute recurrent pancreatitis; causes include anatomic defects resulting in obstruction of the pancreatic duct, use of drugs (especially, chronic alcohol abuse), and underlying genetic or autoimmune disorders of the pancreas. Often, no speific cause can be identified in a proportion of patients, specially in the Asia-Pacific region. Treatment methods have included pancreatic enzyme replacements, pain management, ERCP with stenting, and decompressive surgical procedures of the pancreatic duct, partial resection, and total pancreatectomy. A comprehensive review of the subject was recently published. In paients with chronic pancreatitis (instead of a primary maignancy), the decision to perform a total pancreatectomy is ot an easy one because of the extensive nature of the urgery and the resulting endocrine deficiency, which alost always results in brittle insulin-dependent diabetes ellitus. But the development of autologous islet (autoiset) transplants has provided an opportunity to prevent evelopment of insulin-dependent diabetes mellitus in uch patients. Their quality of life is improved by undergong both procedures: the total pancreatectomy addresses heir pain, and the autoislet transplant maintains their enocrine function. Total pancreatectomy is not a new procedure. Billroth performed the first reported pancreatectomy for pancreatic cancer in 1884; more than 80 years later, Warren performed the first pancreatectomy for intractable pain and

The survival outcomes following liver transplantation (SOFT) score: validation with contemporaneous data and stratification of high‐risk cohorts

Models to project survival after liver transplantation are important to optimize outcomes. We introduced the survival outcomes following liver transplantation (SOFT) score in 2008 (1) and designed to predict survival in liver recipients at three months post‐transplant with a C statistic of 0.70. Our objective was to validate the SOFT score, with more contemporaneous data from the OPTN database. We also applied the SOFT score to cohorts of the sickest transplant candidates and the poorest‐quality allografts. Analysis included 21 949 patients transplanted from August 1, 2006, to October 1, 2010. Kaplan–Meier survival functions were used for time‐to‐event analysis. Model discrimination was assessed using the area under the receiver operating characteristic (ROC) curve. We validated the SOFT score in this cohort of 21 949 liver recipients. The C statistic was 0.70 (CI 0.68–0.71), identical to the original analysis. When applied to cohorts of high‐risk recipients and poor‐quality donor allografts, the SOFT score projected survival with a C statistic between 0.65 and 0.74. In this study, a validated SOFT score was informative among cohorts of the sickest transplant candidates and the poorest‐quality allografts.

Diabetes and landmine‐related amputations: a call to arms to save limbs

The effects of landmine-related morbidity have long been the subject of intense attention by the media, governments and non-governmental organizations alike (1–3). While much remains to be done in this area, it can be argued that major advances have been made (4–6). At the other end of the spectrum, the epidemic of diabetes-related limb amputations continues its inexorable rise; despite a surprisingly high 5-year mortality associated with this preventable scourge, the lay public and press seem largely unaware and policy-makers have failed to appropriately respond (7). In many ways, diabetes-related amputations are strikingly similar to those associated with landmines. This intriguing comparison emphasizes the silent nature of the ‘warfare’ and the sinister consequences on the life of patients/ victims. From a pubic health standpoint, diabetes-related amputations are now more common than those resulting from exploding hidden landmines, leading to 70% of the lower extremity amputations around the world (8). Certainly, huge progress has been made in the areas of offloading, aggressive wound healing protocols and prevention (9,10). But how does this progress compare to the magnitude of the problem, especially when considering the developing and developed nations on the same scale?(11) Undoubtedly, we are currently losing this silent war and much needs to be done at various levels (community, providers, media, government and non-government organizations) if we want to win. Diabetes is a worldwide-epidemic; in 2006, there were more than 230 million individuals with diabetes; in 20 years, this number is expected to reach 350 million. This high incidence of diabetes, coupled with the associated 43–55% 5-year mortality rates after newonset diabetic limb ulceration, which increase up to 74% for patients with lower-extremity amputation, will mount significant pressure on global healthcare infrastructure. It is striking to note that these mortality rates are higher than those for several types of cancer including prostate, breast, colon, and Hodgkin’s disease (7,8,12). While it is inexpensive to produce a landmine(3), the consequences invariably lead to lower extremity amputations, with subsequent loss of livelihood and poor quality of life. ‘A single landmine might cost

Isolated intestinal transplants vs. liver‐intestinal transplants in adult patients in the United States: 22 yr of OPTN data

1, but once in the ground locating it and making it safe can cost up to

Geographic inequities in liver allograft supply and demand: Does it affect patient outcomes?

1000.’ (13,14) We face a daunting uphill task in combating an even more treacherous and formidable foe. Diabetes is often silent, lurking beneath the clinical surface; a foot ulceration or infection is a common early manifestation during the course of the disease. It is usually underlying neuropathy, which leads to foot ulceration. A Semmes-Weinstein filament costs pennies to produce and is often provided free to diabetes care clinics around the world; its more widespread use to detect diabetic neuropathy in its early stages would be an enormously costeffective equivalent of expensive detectors to search for unexploded landmines. Extensive new initiatives by the World Diabetes Federation (WDF) and World Health Organization (WHO), especially in developing countries, to improve the treatment of diabetes and implement targeted and proven prevention strategies have certainly helped to combat this epidemic. Organized prevention efforts coupled with timely and aggressive interventions when needed can improve patient outcomes and reduce amputation rates. (15) Landmine-related amputations are a global problemaffecting84countriesandeight territories Editorial Information

Early liver retransplantation in adults

Desai CS, Gruessner AC, Khan KM, Fishbein TM, Jie T, Rodriguez Rilo HL, Gruessner RWG. Isolated intestinal transplants vs. liver‐intestinal transplants in adult patients in the United States: 22 yr of OPTN data.

The Micrograft Concept for Wound Healing: Strategies and Applications

Background Significant geographic inequities mar the distribution of liver allografts for transplantation. Methods We analyzed the effect of geographic inequities on patient outcomes. During our study period (January 1 through December 31, 2010), 11,244 adult candidates were listed for liver transplantation: 5,285 adult liver allografts became available, and 5,471 adult recipients underwent transplantation. We obtained population data from the 2010 United States Census. To determine the effect of regional supply and demand disparities on patient outcomes, we performed linear regression and multivariate Cox regression analyses. Results Our proposed disparity metric, the ratio of listed candidates to liver allografts available varied from 1.3 (region 11) to 3.4 (region 1). When that ratio was used as the explanatory variable, the R2 values for outcome measures were as follows: 1-year waitlist mortality, 0.23 and 1-year posttransplant survival, 0.27. According to our multivariate analysis, the ratio of listed candidates to liver allografts available had a significant effect on waitlist survival (hazards ratio, 1.21; 95% confidence interval, 1.04–1.40) but was not a significant risk factor for posttransplant survival. Conclusion We found significant differences in liver allograft supply and demand—but these differences had only a modest effect on patient outcomes. Redistricting and allocation-sharing schemes should seek to equalize regional supply and demand rather than attempting to equalize patient outcomes.

Use of Sugar on the Healing of Diabetic Ulcers: A Review

Up to 23% of liver allografts fail post‐transplant. Retransplantation is only the recourse but remains controversial due to inferior outcomes. The objective of our study was to identify high‐risk periods for retransplantation and then compare survival outcomes and risk factors. We performed an analysis of United Network for Organ Sharing (UNOS) data for all adult liver recipients from 2002 through 2011. We analyzed the records of 49 288 recipients; of those, 2714 (5.5%) recipients were retransplanted. Our analysis included multivariate regression with the outcome of retransplantation. The highest retransplantation rates were within the first week (19% of all retransplantation, day 0–7), month (20%, day 8–30), and year (33%, day 31–365). Only retransplantation within the first year (day 0–365) had below standard outcomes. The most significant risk factors were as follows: within the first week, cold ischemia time >16 h [odds ratio (OR) 3.6]; within the first month, use of split allografts (OR 2.9); and within the first year, use of a liver donated after cardiac death (OR 4.9). Each of the three high‐risk periods within the first year had distinct causes of graft failure, risk factors for retransplantation, and survival rates after retransplantation.

Patient quality of life and pain improve after autologous islet transplantation (AIT) for treatment of chronic pancreatitis: 53 patient series at the University of Arizona

The standard of care for wound coverage is to use an autologous skin graft. However, large or chronic wounds become an exceptionally challenging problem especially when donor sites are limited. It is important that the clinician be aware of various treatment modalities for wound care and incorporate those methods appropriately in the proper clinical context. This report reviews an alternative to traditional meshed skin grafting for wound coverage: micrografting. The physiological concept of micrografting, along with historical context, and the evolution of the technique are discussed, as well as studies needed for micrograft characterization and future applications of the technique.