Qualitative analysis of subcutaneous Lispro and regular insulin injections for stress hyperglycemia: a pilot numerical study.

Increased glucose variability (GV) is an independent risk factor for mortality in the critically ill; unfortunately, the optimal insulin therapy that minimizes GV is not known. We simulate the glucose-insulin feedback system to study how stress hyperglycemia (SH) states, taken to be a non-uniform group of physiologic disorders with varying insulin resistance (IR) and similar levels of hyperglycemia, respond to the type and dose of subcutaneous (SQ) insulin. Two groups of 100 virtual patients are studied: those receiving and those not receiving continuous enteral feeds. Stress hyperglycemia was facilitated by doubling the gluconeogenesis rate and IR was stepwise varied from a borderline to a high value. Lispro and regular insulin were simulated with dosages that ranged from 0 to 6 units; the resulting GV was analyzed after each insulin injection. The numerical model used consists of a set of non-linear differential equations with two time delays and five adjustable parameters. The results show that regular insulin decreased GV in both patient groups and rarely caused hypoglycemia. With continuous enteral feeds and borderline to mild IR, Lispro showed minimal effect on GV; however, rebound hyperglycemia that increased GV occurred when the IR was moderate to high. Without a nutritional source, Lispro worsened GV through frequent hypoglycemia episodes as the injection dose increased. The inferior performance of Lispro is a result of its rapid absorption profile; half of its duration of action is similar to the glucose ultradian period. Clinical trials are needed to examine whether these numerical results represent the glucose-insulin dynamics that occur in intensive care units, and if such dynamics are present, their clinical effects should be evaluated.

A retrospective study evaluating the use of Permacol™ surgical implant in incisional and ventral hernia repair.

BACKGROUND: The outcome of incisional and ventral hernia repair depends on surgical technique, patient, and material. Permacol™ surgical implant (crosslinked porcine collagen) has been used for over a decade; however, there are few data on outcomes. This study is the largest retrospective multinational study to date to evaluate outcomes with Permacol™ surgical implant in the repair of incisional and ventral hernias. METHODS: Data were collected retrospectively on 343 patients treated for 213 incisional and 130 ventral hernias. Data evaluated included patient demographics, wound classification, surgical technique, morbidity, and recurrence rates. RESULTS: Median follow-up time was 649 days (max: 2857), median age 57 years (range 23-91), and BMI 32 kg/m(2) (range 17.6-77.8). Two or more comorbidities were present in 70% of patients. Open surgery was performed in 220 (64%) patients. Permacol™ surgical implant was used as an underlay (250), sublay (39), onlay (37), or inlay (17). Surgical techniques included component separation (89; 25.9%), modified Stoppa technique (197; 57.4%), and Rives-Stoppa (17; 5.0%). CDC Surgical Wound Classification was Class I (190), Class II (103), Class III (28), and Class IV (22). Complications were seen in 40.5% (139) of the patients, with seroma (19%) and wound infection (15%) as the most common. Mesh removal occurred in 1 (0.3%) patient. Kaplan-Meier analysis demonstrated that the probabilities for hernia recurrence at one, two, and three years were 5.8%, 16.6%, and 31.0%, respectively. CONCLUSIONS: Permacol™ surgical implant was shown to be safe with relatively low rates of hernia recurrence. CLINICAL TRIAL REGISTRATION NUMBER: NCT01214252 (http://www.clinicaltrials.gov).

Positive and negative volume-outcome relationships in the geriatric trauma population.

IMPORTANCE: In trauma populations, improvements in outcome are documented in institutions with higher case volumes. However, it is not known whether improved outcomes are attributable to the case volume within specific higher-risk groups, such as the elderly, or to the case volume among all trauma patients treated by an institution. OBJECTIVE: To test the hypothesis that outcomes of trauma care for geriatric patients are affected differently by the volume of geriatric cases and nongeriatric cases of an institution. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study using a statewide trauma registry was set in state-designated levels 1 and 2 trauma centers in Pennsylvania. It included 39 431 eligible geriatric trauma patients (aged >65 years) in the Pennsylvania Trauma Outcomes Study. MAIN OUTCOMES AND MEASURES: In-hospital mortality, major complications, and mortality after major complications (failure to rescue). RESULTS: Between 2001 and 2010, 39 431 geriatric trauma patients and 105 046 nongeriatric patients were captured in a review of outcomes in 20 state-designated levels 1 and 2 trauma centers. Larger volumes of geriatric trauma patients were significantly associated with lower odds of in-hospital mortality, major complications, and failure to rescue. In contrast, larger nongeriatric trauma volumes were significantly associated with higher odds of major complications in geriatric patients. CONCLUSIONS AND RELEVANCE: Higher rates of in-hospital mortality, major complications, and failure to rescue were associated with lower volumes of geriatric trauma care and paradoxically with higher volumes of trauma care for younger patients. These findings offer the possibility that outcomes might be improved with differentiated pathways of care for geriatric trauma patients.

The impact of intensivists' base specialty of training on care process and outcomes of critically ill trauma patients.

BACKGROUND: The care of the critically ill trauma patients is provided by intensivists with various base specialties of training. The purpose of this study was to investigate the impact of intensivists' base specialty of training on the disparity of care process and patient outcome. METHODS: We performed a retrospective review of an institutional trauma registry at an academic level 1 trauma center. Two intensive care unit teams staffed by either board-certified surgery or anesthesiology intensivists were assigned to manage critically ill trauma patients. Both teams provided care, collaborating with a trauma surgeon in house. We compared patient characteristics, care processes, and outcomes between surgery and anesthesiology groups using Wilcoxon tests or chi-square tests, as appropriate. RESULTS: We identified a total of 620 patients. Patient baseline characteristics including age, sex, transfer status, injury type, injury severity score, and Glasgow coma scale were similar between groups. We found no significant difference in care processes and outcomes between groups. In a logistic regression model, intensivists' base specialty of training was not a significant factor for mortality (odds ratio, 1.46; 95% confidence interval; 0.79-2.80; P = 0.22) and major complication (odds ratio, 1.11; 95% confidence interval, 0.73-1.67; P = 0.63). CONCLUSIONS: Intensive care unit teams collaborating with trauma surgeons had minimal disparity of care processes and similar patient outcomes regardless of intensivists' base specialty of training.

Pelvic fractures in pregnancy: factors influencing maternal and fetal outcomes.

BACKGROUND: The purpose of this study was to determine factors influencing maternal and fetal outcomes associated with pelvic fractures in pregnancy. METHODS: A literature review of pelvic and acetabular fractures during pregnancy was performed, providing 101 cases for analysis (1 case report was included). Factors influencing maternal and fetal mortality were evaluated. RESULTS: Pelvic and acetabular fractures during pregnancy were associated with a high maternal (9%) and a higher fetal (35%) mortality rate. Automobile-pedestrian collisions had a trend toward a higher maternal mortality rate, and vehicular collisions had a trend toward a higher fetal mortality rate, compared with falls. Injury severity influenced both maternal and fetal outcomes. Fracture classification (simple vs. complex), fracture type (acetabular vs. pelvic), the trimester of pregnancy, and the era of literature reviewed did not influence mortality rates. When considering potential causes of fetal death, direct trauma to the uterus, placenta, or fetus was not associated with a higher fetal mortality rate, compared with maternal hemorrhage. Pelvic and acetabular fracture surgery has rarely been reported in this patient population. CONCLUSION: Pelvic and acetabular fractures in pregnancy continue to be associated with a high fetal mortality rate. Mechanism of injury and injury severity appeared to influence mortality rates, whereas the fracture classification, the fracture type, the trimester of pregnancy, and the era of literature reviewed did not.