Juan J. Blondet

Islet autotransplant outcomes after total pancreatectomy: a contrast to islet allograft outcomes.

Introduction. Islet allografts are currently associated with a high rate of early insulin independence, but after 1 year insulin-independence rates rapidly decline for unclear reasons. In contrast, as shown here, islet autotransplants (IATs) show durable function and extended insulin-independence rates, despite a lower beta-cell mass. Methods. IAT function was determined in 173 patients after total pancreatectomy at our center. Islet function was considered full in insulin-independent patients, partial when euglycemic on once-daily long-acting insulin (all tested were C-peptide positive), and failed if on a standard diabetic regimen. Outcomes for autoislet recipients by Kaplan-Meier survival analysis were compared with those of alloislet recipients in the Collaborative Islet Transplant Registry. Results. IAT function (full/partial combined) and insulin independence correlated with islet yield. Overall only 65% functioned within the first year, and only 32% were insulin independent, but of IATs that functioned initially (n=112), 85% remained so 2-years later, in contrast to 66% of allografts (n=262). Of IAT recipients who became insulin independent (n=55), 74% remained so 2-years later versus 45% of initially insulin-independent allograft recipients (n=154). Of IATs that functioned or induced insulin independence, the rates at 5 years were 69% and 47%, respectively. Conclusion. Islet function is more resilient in autografts than allografts. Indeed, the 5-year insulin-independence persistence rate for IATs is similar to the 2-year rate for allografts. Several factors unique to allocases are likely responsible for the differences, including donor brain death, longer cold ischemia time, diabetogenic immunosuppression, and auto- and alloimmunity. IAT outcomes provide a minimum theoretical standard to work toward in allotransplantation.

Early hypothermia in severely injured trauma patients is a significant risk factor for multiple organ dysfunction syndrome but not mortality

Objective:To evaluate the relationship of early hypothermia to multiple organ failure and mortality in a prospectively-collected database of severely injured trauma patients. Methods:This prospective observational study was performed at 7 level I trauma centers over a 16-month period. Severely injured trauma patients with signs of hypoperfusion (eg, base deficit, hypotension) and need for blood transfusion during their early hospital course were followed for 24 hours with near infrared spectroscopy-derived tissue oxygen saturation (StO2) and other variables for 28 days to evaluate outcomes including multiple organ dysfunction syndrome (MODS) and death. Early hypothermia was defined as the presence of a temperature ≥35°C anytime within the first 6 hours of hospitalization. Comparisons between groups were made using the Wilcoxon Two-Sample test for continuous variables and either the Fisher exact or &khgr;2 test for categorical variables. Multivariate logistic regression was utilized to understand the effect of hypothermia on outcome (MODS and mortality). Results:Hypothermia was very common in this cohort of patients, present in 43% of patients enrolled (155/359). Hypothermic patients were 3 times more likely than normothermic patients to develop MODS (21% vs. 9%, P = 0.003). Hypothermic patients did not have an increased incidence of mortality (16% vs. 12%, P= 0.2826). Base deficit in hypothermic patients did not discriminate between patients who did or did not develop MODS (9.8 + 4.6 mEq/L vs. 9.4 + 4.4 mEq/L), but had good discrimination for mortality in both hypothermic and normothermic patients. Significant predictors of MODS using multivariate analysis included minimum StO2 (P= 0.0014) and hypothermia (P = 0.0371). Predictors for mortality using multivariate analysis included minimum StO2 (P= 0.0021) and base deficit (P= 0.0454), but not hypothermia (P= 0.5289). Hypothermia remained a significant risk factor for MODS when systolic blood pressure, volume of fluid, and volume of blood infused were included in the multivariate model. Conclusion:Hypothermia is common in severely injured trauma patients (nearly half of patients in this series) and is a significant risk factor for MODS but not mortality. The predictive value of base deficit for development of MODS is blunted in the presence of hypothermia. A low StO2 value predicts MODS and mortality in trauma patients and is a durable measure in both normothermic and hypothermic patient groups.

Glycemic control and prevention of perioperative infection.

Purpose of reviewHyperglycemia is common during perioperative management of surgical and critically ill patients. There is extensive ongoing study of detrimental effects associated with hyperglycemia, with several remaining unanswered questions. This review discusses recent literature on tight glucose control with insulin therapy and its effects in prevention and management of infection. Recent findingsHyperglycemia affects multiple pathways of the immune system, resulting in decreased phagocytic and chemotactic functions in neutrophils and monocytes, as well as increased rates of apoptosis of the former and decreased ability of the latter to present antigen. Intensive insulin therapy has been shown to counteract many of these deleterious effects. Clinically, the benefits of tight glucose control have been evaluated in different patient populations with conclusions that remain varied. Hypoglycemia as a complication of tight glucose control continues to be an issue and has led to discontinuation of two large-scale studies. The clinical relevance of hypoglycemic events remains unclear. SummaryHyperglycemia impairs the cellular immune system, stimulates inflammatory cytokines, and affects the microcirculation, thus increasing risk for infection and preventing normal wound healing. Additional investigation is needed to define appropriate patient populations and to develop effective treatment strategies for preventing perioperative morbidity.

Predicting islet yield in pediatric patients undergoing pancreatectomy and autoislet transplantation for chronic pancreatitis.

Bellin MD, Blondet JJ, Beilman GJ, Dunn TyB, Balamurugan AN, Thomas W, Sutherland DER, Moran A. Predicting islet yield in pediatric patients undergoing pancreatectomy and autoislet transplantation for chronic pancreatitis.

Near-infrared spectroscopy-derived tissue oxygen saturation in battlefield injuries: a case series report

BackgroundNear-infrared spectroscopy technology has been utilized to monitor perfusion status in animal models of hemorrhagic shock and in human traumatic injury. To observe the effectiveness of such a device in a combat setting, an FDA-approved device was used in conjunction with standard resuscitation and therapy of wounded patients presenting to the 228th Combat Support Hospital (CSH), Company B, over a three-month period.Materials and methodsThese observations were performed on patients presenting to the 228th CSH, Co B, at Forward Operating Base Speicher, outside of Tikrit, Iraq, between the dates of June 15 and September 11, 2005. We utilized the Inspectra™ 325 tissue oxygen saturation (StO2) monitor (Hutchinson Technology, Inc; Hutchinson, MN, USA) with the probe placed on the thenar eminence or on another appropriate muscle bed, and used to monitor StO2 during early resuscitation and stabilization of patients.ResultsDuring the above time period, 161 patients were evaluated at the CSH as a result of traumatic injury and the device was placed on approximately 40 patients. In most patients, StO2 readings of greater than 70% were noted during the initial evaluation. No further information was collected from these patients. In 8 patients, convenience samples of StO2 data were collected along with pertinent physiologic data. In these patients, StO2 levels of below 70% tracked with hypotension, tachycardia, and clinical shock resulted in increases in StO2 after resuscitation maneuvers.ConclusionNear-infrared spectroscopy-derived StO2 reflected and tracked the resuscitation status of our patients with battlefield injuries. StO2 has significant potential for use in resuscitation and care of patients with battlefield injuries.

Evaluation of Isolated Rib Lesions With Radionuclide-Guided Biopsy

BACKGROUND Isolated rib lesions detected on bone scanning can pose a diagnostic challenge, particularly in patients with a known primary cancer. The purpose of our study was to assess the diagnostic value of radionuclide-guided rib biopsy with an intraoperative gamma probe. METHODS We conducted a retrospective chart review of 10 patients who underwent an intraoperative gamma probe-guided rib biopsy. Rib defects were identified by radionuclide bone scan. Patients received an intravenous dose of technetium 99m methylene diphosphonate within 6 hours before surgery. The approximate location of the rib defect was scanned with a hand-held gamma probe intraoperatively; an excisional rib biopsy was performed in the area with the highest tracer activity. RESULTS Median age was 54 years (range, 40 to 83) and median body mass index was 32.5 (range, 23 to 52). Seven patients had a known primary extraosseous cancer and 3 patients had no history of cancer. Seven patients had pain at the time of initial evaluation. The median operative time was 45 minutes, median operative blood loss was 25 mL, and median length of stay was 1 day. Complications occurred in 2 patients: a pneumothorax that did not require treatment and a delayed hemothorax that required tube thoracostomy. Rib biopsy was accurate in all 10 patients; metastatic disease was found in 5 of 7 cancer patients. Pain improved or resolved in 4 patients. CONCLUSIONS The evaluation of isolated rib lesions using radionuclide-guided rib biopsy with an intraoperative hand-held gamma probe is accurate and potentially therapeutic. Thoracic surgeons and oncologists should be aware of this approach.

Survey of surgical infections currently known (SOSICK): A multicenter examination of antimicrobial use from the Surgical Infection Society Scientific Studies Committee

PURPOSE The Scientific Studies Committee of the Surgical Infection Society undertook the present study to examine the prevalence of and indications for antimicrobial use in intensive care units where members of the Society practice. METHODS Information and data collection sheets were posted on the Internet for download by members interested in participating. All centers were required to obtain approval from their local human subjects research office or equivalent. A one-week time was set during which the center could collect information on any one day, at the centers convenience. Data collection sheets were then sent to the lead author for analysis. Seventeen centers reported data for 371 patients in 22 intensive care units. RESULTS Trauma and general surgical patients comprised 224 of the patients (60%). The indications for anti-infective agents were prophylactic (22%), empiric (27%), therapeutic with known pathogen (41%), therapeutic without known pathogen (e.g., cellulitis) (4%), insistence of influential practitioner (4%), or non-anti-infective purposes (e.g., erythromycin for gastric motility) (2%). Only 44%, 29%, and 54% of the orders for prophylactic, empiric, and therapeutic antibiotics, respectively, had date-certain stop dates. The antimicrobial drugs most commonly used were vancomycin, piperacillin-tazobactam, and fluconazole. CONCLUSION Most patients were receiving antimicrobial agents. Polypharmacy was common. Most patients did not have a date-certain stop date. This study sets the benchmark for future study regarding antibiotic prescribing behavior in surgical intensive care units.