XI. STRATEGIES FOR IMPROVING DIABETES CARE D iabetes is a chronic illness that requires continuing medical care and patient self-management education to prevent acute complications and to reduce the risk of long-term complications. Diabetes care is complex and requires that many issues, beyond glycemic control, be addressed. A large body of evidence exists that supports a range of interventions to improve diabetes outcomes. These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care. While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided. These standards are not intended to preclude more extensive evaluation and management of the patient by other specialists as needed. For more detailed information, refer to Bode (Ed.): Medical Management of Type 1 Diabetes (1), Burant (Ed): Medical Management of Type 2 Diabetes (2), and Klingensmith (Ed): Intensive Diabetes Management (3). The recommendations included are diagnostic and therapeutic actions that are known or believed to favorably affect health outcomes of patients with diabetes. A grading system (Table 1), developed by the American Diabetes Association (ADA) and modeled after existing methods, was utilized to clarify and codify the evidence that forms the basis for the recommendations. The level of evidence that supports each recommendation is listed after each recommendation using the letters A, B, C, or E.

Standards of Medical Care in Diabetes

OBJECTIVE — To systematically review the incidence of posttransplantation diabetes (PTD), risk factors for its development, prognostic implications, and optimal management. RESEARCH DESIGN AND METHODS — We searched databases (MEDLINE, EMBASE, the Cochrane Library, and others) from inception to September 2000, reviewed bibliographies in reports retrieved, contacted transplantation experts, and reviewed specialty journals. Two reviewers independently determined report inclusion (original studies, in all languages, of PTD in adults with no history of diabetes before transplantation), assessed study methods, and extracted data using a standardized form. Meta-regression was used to explain between-study differences in incidence. RESULTS — Nineteen studies with 3,611 patients were included. The 12-month cumulative incidence of PTD is lower (10% in most studies) than it was 3 decades ago. The type of immunosuppression explained 74% of the variability in incidence (P 0.0004). Risk factors were patient age, nonwhite ethnicity, glucocorticoid treatment for rejection, and immunosuppression with high-dose cyclosporine and tacrolimus. PTD was associated with decreased graft and patient survival in earlier studies; later studies showed improved outcomes. Randomized trials of treatment regimens have not been conducted. CONCLUSIONS — Physicians should consider modification of immunosuppressive regimens to decrease the risk of PTD in high-risk transplant recipients. Randomized trials are needed to evaluate the use of oral glucose-lowering agents in transplant recipients, paying particular attention to interactions with immunosuppressive drugs. Diabetes Care 25:583–592, 2002

A systematic review of the literature

Fibroblasts can condense a hydrated collagen lattice to a tissue-like structure 1/28th the area of the starting gel in 24 hr. The rate of the process can be regulated by varying the protein content of the lattice, the cell number, or the con- centration of an inhibitor such as Colcemid. Fibroblasts of high population doubling level propagated in vitro, which have left the cell cycle, can carry out the contraction at least as efficiently as cycling cells. The potential uses of the system as an immu- nologically tolerated "tissue" for wound hea ing and as a model for studying fibroblast function are discussed.

Production of a tissue-like structure by contraction of collagen lattices by human fibroblasts of different proliferative

These guidelines were developed jointly by the American Society of Health-System Pharmacists (ASHP), the Infectious Diseases Society of America (IDSA), the Surgical Infection Society (SIS), and the Society for Healthcare Epidemiology of America (SHEA). This work represents an update to the

/pdf/clinical-practice-guidelines-for-antimicrobial-prophylaxis-1gq1adk8ux.pdf

Clinical practice guidelines for antimicrobial prophylaxis in surgery

The American Society for Apheresis (ASFA) Journal of Clinical Apheresis (JCA) Special Issue Writing Committee is charged with reviewing, updating, and categorizing indications for the evidence-based use of therapeutic apheresis in human disease. Since the 2007 JCA Special Issue (Fourth Edition), the Committee has incorporated systematic review and evidence-based approaches in the grading and categorization of apheresis indications. This Seventh Edition of the JCA Special Issue continues to maintain this methodology and rigor to make recommendations on the use of apheresis in a wide variety of diseases/conditions. The JCA Seventh Edition, like its predecessor, has consistently applied the category and grading system definitions in the fact sheets. The general layout and concept of a fact sheet that was used since the fourth edition has largely been maintained in this edition. Each fact sheet succinctly summarizes the evidence for the use of therapeutic apheresis in a specific disease entity. The Seventh Edition discusses 87 fact sheets (14 new fact sheets since the Sixth Edition) for therapeutic apheresis diseases and medical conditions, with 179 indications, which are separately graded and categorized within the listed fact sheets. Several diseases that are Category IV which have been described in detail in previous editions and do not have significant new evidence since the last publication are summarized in a separate table. The Seventh Edition of the JCA Special Issue serves as a key resource that guides the utilization of therapeutic apheresis in the treatment of human disease. J. Clin. Apheresis 31:149-162, 2016. © 2016 Wiley Periodicals, Inc.

Guidelines on the Use of Therapeutic Apheresis in Clinical Practice—Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Sixth Special Issue

Vascularized pancreas transplantation was developed as a means to reestablish endogenous insulin secretion responsive to normal feedback controls. Pancreas transplantation is currently the only available form of autoregulating total endocrine replacement therapy that reliably establishes an insulin-independent euglycemic state and normal glucose homeostasis, resulting in the successful treatment of diabetes mellitus. With improvements in organ retrieval and preservation technology, refinements in diagnostic technology and surgical techniques, advances in clinical immunosuppression and antimicrobial prophylaxis, and experience in donor and recipient selection, success rates for pancreas transplantation have steadily increased. From 1966 through July 2000, more than 14,000 pancreas transplants were performed worldwide and reported to the International Pancreas Transplant Registry (IPTR). 1 In the United States, more than 1,200 pancreas transplants are performed annually, with 83% being simultaneous kidney and pancreas transplantations (SKPTs). The current 1-year actuarial patient, kidney, and pancreas (with complete insulin independence) graft survival rates after SKPT are 95%, 92%, and 84%, respectively. 1 With the advent of Medicare coverage, SKPT has become accepted as the preferred treatment option in selected patients with insulin-dependent diabetes mellitus and advanced nephropathy.

The history of clinical pancreas transplantation largely revolves around the development and application of various surgical techniques. According to IPTR data, most pancreas transplants are performed with systemic venous delivery of insulin and either bladder (systemic-bladder [SB]) or enteric (systemic-enteric [SE]) drainage of the exocrine secretions. 1,2 From 1988 through 1995, more than 90% of pancreas transplants were performed by the standard technique of SB drainage. 2 With an evolution in surgical techniques, a resurgence of interest has occurred in enteric exocrine drainage. Since 1995, the number of pancreas transplants performed with primary enteric drainage has steadily increased, accounting for 60% of cases in 1999. 1

Most pancreas transplants with enteric drainage are performed with systemic venous delivery of insulin (SE technique). 2 To improve the physiology of pancreas transplantation and to avoid the potential complications of systemic hyperinsulinemia (e.g., dyslipidemia, accelerated atherosclerosis, and insulin resistance), a new surgical technique was developed at our center using portal venous delivery of insulin and enteric drainage of the exocrine secretions (portal-enteric [PE]). 3,4 However, the proportion of cases with enteric exocrine drainage coupled with portal venous delivery of insulin has remained low and represents only 15% to 20% of enteric-drained pancreas transplants. 2 In the most recent IPTR analysis including pancreas transplants performed between 1996 to 1999, the 1-year pancreas graft survival rates were similar for PE versus SE drainage (83% and 84%, respectively). 1 The purpose of this study was to compare SKPT with SE versus PE drainage in a prospective fashion with standardized immunosuppression.

A prospective comparison of simultaneous kidney-pancreas transplantation with systemic-enteric versus portal-enteric drainage.

Vascular complications following orthotopic liver transplantation: outcome and the role of urgent revascularization.

We initiated a policy of using RSLT in critically ill patients in June of 1988. Since that time we have performed 30 RSLTs in 29 patients, including 28 children and 1 adult. The mean age of the children was 27 months (range 1 month to 10 years) with 14 (52%) being 1 year of age or less. The mean weight was 11.3 kg (range 2-50 kg) with 20 being 10 kg or less. A total of 22 patients were in the intensive care unit at the time of RSLT including 9 who were intubated. Of the 30 RSLTs, 23 were performed as a primary transplant while 7 were retransplants. Indications for primary transplantation included biliary atresia (n = 11), fulminant hepatic failure (n = 5), neonatal hepatitis (n = 4) and others (n = 3). The RSLT was used in retransplantation for primary nonfunction (n = 2), hepatic artery thrombosis (n = 2), chronic rejection (n = 2), and herpetic hepatitis (n = 1). The size reductions included 18 left lobes, 7 left lateral segments, and 5 right lobes. This group includes the use of the split-liver technique, which was applied to 10 patients (5 livers). The median donor/recipient weight ratio for left lobe transplants was 2:1; left lateral segments was 7.3:1; and right lobes 1.6:1. One year actuarial patient and graft survivals were 68 and 65%, respectively, with a mean follow-up of 10.6 months. The number of children dying awaiting transplantation has been significantly reduced following the introduction of RSLD (3 of 115, 2.6% vs. 12 of 95, 13%; P less than 0.02).

The results of reduced-size liver transplantation, including split livers, in patients with end-stage liver disease.

Purpose of review Pancreas graft thrombosis remains one of the most common reasons for pancreas transplant loss. Patients with a history of thrombotic events should be identified and evaluated for thrombophilia to identify transplant candidates at highest risk. Recent findings Early after transplant, vascular thrombosis is multifactorial, but beyond 2 weeks, inflammation or acute rejection predominate as the cause of thrombosis. Most pancreas transplant centers utilize some form of anticoagulation following transplantation. Aspirin is highly recommended. Unfractionated or low-molecular-weight heparin is often administered, but some centers use heparin selectively and typically at low dose to avoid postoperative bleeding. Warfarin is less frequently given and its use should probably be limited to patients with thrombophilia. Summary Thrombectomy, either surgical or percutaneous, may salvage the pancreas graft if performed early after the occurrence of thrombosis.

Pancreas graft thrombosis: causes, prevention, diagnosis, and intervention.

The complications of long-term steroid immunosuppression are well known. During a 12-month period, 52 living-donor renal transplant recipients were entered into a protocol of intentional early steroid withdrawal. Selection criteria were primary living-related renal transplants in HLA-identical (12) or one-haplotype match (40) patients. The study population consisted of 25 diabetics (48.1%) with a mean age of 32.4 years. All patients received preoperative blood transfusions (3 donor-specific in haplotype-matched, 3 random in HLA-identical recipients). Immunosuppression consisted of cyclosporine, azathioprine, and corticosteroids, with deliberate steroid withdrawal after two weeks. Forty-six patients (88.5%) were successfully tapered off steroids, while the six protocol failures (11.5%) were due to early rejection or leukopenia that prevented steroid withdrawal. Twenty-three patients (50%) subsequently were returned to steroid therapy for rejection (21) or leukopenia (2). Inadequate immunosuppression precipitated six rejection episodes and were preventable, while the remaining 15 were true breakthrough crises. The overall rejection rate was 50%, with 92.3% of initial rejection episodes occurring within five weeks of steroid withdrawal. Rejection episodes were responsive to steroid therapy alone in 73.2% of cases. No graft loss from rejection has occurred after a mean follow-up interval of 8.5 months. At present, 33 patients (63.5%) are off steroids. In HLA-identical recipients, all but one successfully completed the protocol and 75% are currently steroid-free. In haplotype-matched patients, 87.5% completed the protocol and 60% are steroid-independent. Comparison with well-matched control groups on steroids failed to reveal any difference in graft or patient survival, rejection, infection, or mean serum creatinine level. No discriminating risk factors could be identified that were predictive of steroid withdrawal success or failure. In select patients, early steroid withdrawal can be accomplished without jeopardizing graft function. Long-term follow-up is required to assess the risk-benefit ratio of steroid withdrawal upon immunosuppressive morbidity.

Robert J. Stratta

Papers

A prospective comparison of simultaneous kidney-pancreas transplantation with systemic-enteric versus portal-enteric drainage.

Vascular complications following orthotopic liver transplantation: outcome and the role of urgent revascularization.

The results of reduced-size liver transplantation, including split livers, in patients with end-stage liver disease.

Pancreas graft thrombosis: causes, prevention, diagnosis, and intervention.

Withdrawal of steroid immunosuppression in renal transplant recipients.