HYPERLIPEMIA IN PATIENTS WITH ACUTE PANCREATITIS

Long-Term Retrospective Analysis of Gene Therapy with Alipogene Tiparvovec and Its Effect on Lipoprotein Lipase Deficiency-Induced Pancreatitis

Alipogene tiparvovec (Glybera) is a gene therapy product approved in Europe under the "exceptional circumstances" pathway as a treatment for lipoprotein lipase deficiency (LPLD), a rare genetic disease resulting in chylomicronemia and a concomitantly increased risk of acute and recurrent pancreatitis, with potentially lethal outcome. This retrospective study analyzed the frequency and severity of pancreatitis in 19 patients with LPLD up to 6 years after a single treatment with alipogene tiparvovec. An independent adjudication board of three pancreas experts, blinded to patient identification and to pre- or post-gene therapy period, performed a retrospective review of data extracted from the patients' medical records and categorized LPLD-related acute abdominal pain events requiring hospital visits and/or hospitalizations based on the adapted 2012 Atlanta diagnostic criteria for pancreatitis. Both entire disease time period data and data from an equal time period before and after gene therapy were analyzed. Events with available medical record information meeting the Atlanta diagnostic criteria were categorized as definite pancreatitis; events treated as pancreatitis but with variable levels of laboratory and imaging data were categorized as probable pancreatitis or acute abdominal pain events. A reduction of approximately 50% was observed in all three categories of the adjudicated post-gene therapy events. Notably, no severe pancreatitis and only one intensive care unit admission was observed in the post-alipogene tiparvovec period. However, important inter- and intraindividual variations in the pre- and post-gene therapy incidence of events were observed. There was no relationship between the posttreatment incidence of events and the number of LPL gene copies injected, the administration of immunosuppressive regimen or the percent triglyceride decrease achieved at 12 weeks (primary end point in the prospective clinical studies). Although a causal relationship cannot be established and despite the limited number of individuals evaluated, results from this long-term analysis suggest that alipogene tiparvovec was associated with a lower frequency and severity of pancreatitis events, and a consequent overall reduction in health care resource use up to 6 years posttreatment.

Solutions to Intraoperative Wound Classification Miscoding in a Subset of American College of Surgeons National Surgical Quality Improvement Program Patients

Intraoperative wound classification is a predictor of postoperative infection. Therefore, accurately assigning the correct classification to a surgical wound is of particular importance. Our institution participates in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP), a national outcomes database that collects wound classification for all qualifying operative procedures, and we noted discrepancies when comparing ACS NSQIP wound classification coding with perioperative coding in our electronic medical record. We tested the effectiveness of an intervention that included staff educational sessions, informational posters, and postoperative debriefings on improving the accuracy of documented intraoperative wound classification. The χ2 test was used to compare proportions of wound classification miscodings before and after educational sessions and debriefings commenced. Baseline data revealed misclassification of wounds occurred 21 per cent (30 of 141) of the time in predominately colorectal procedures performed by two surgeons from April through August 2012. Errors decreased to 9 per cent (13 of 147) from August to December 2012, after our intervention of education sessions with operating room staff and the surgeons incorporating a statement confirming the wound classification at the end of the case debriefing. The χ2 statistic was 8.7589. The P value was significant at 0.003. Ensuring concordance of classification between the surgeon and nurse during a post-procedure debriefing as well as education of perioperative nursing staff through posters and seminars significantly improved the accuracy of intraoperative wound classification coding.

Developmental and metabolic disorders of the pancreas

The pancreas is an important exocrine and endocrine organ that develops from the dorsal and ventral anlagen during embryogenesis and arises from the endodermal lining of the duodenum within the first month of human embryonic life. A number of developmental disorders can either lead to anatomic abnormalities of the pancreas and its ducts, or can be part of complex disorders that affect multiorgan systems. Other genetic changes can lead to metabolic abnormalities that affect the pancreas exclusively or increase the lifetime risk for developing pancreatitis or pancreatic diabetes. This article reviews some of the developmental and metabolic disorders that can affect the endocrine and exocrine pancreas.

Acute and chronic pancreatitis in patients with inborn errors of metabolism

Acute and chronic recurrent pancreatitis have been reported in patients with a variety of inborn errors of metabolism. Among these are hyperlipidaemias, various disorders of branched-chain amino acid degradation, homocystinuria, haemolytic disorders, acute intermittent porphyria and several amino acid transporter defects. Some of these disease entities are exceedingly rare. In most of these disorders, pancreatitis is not very common and, with the exception of lipoprotein lipase and apolipoprotein C-II deficiency, is neither the leading nor the clinically most distressing manifestation of the underlying metabolic defect. The majority of these syndromes are, however, inherited, and often entire kindreds are carriers of well-defined germline mutations that can, to varying degrees, be associated with pancreatitis. We have reviewed the clinical, biochemical and genetic characteristics of those inborn errors of metabolism because interesting information can be gained from the in regard to the pathophysiology of pancreatitis and because they need to be distinguished from other hereditary causes of the disease.

Risk factors for infection in patients with traumatic lacerations

BACKGROUND

Most of our knowledge of laceration management comes from studies in animal models or patients with closure of sterile postoperative surgical incisions. Traumatic laceration management has not been well studied.

OBJECTIVE

To determine which characteristics of traumatic lacerations were associated with the development of wound infection.

METHODS

A cross-sectional study of consecutive patients with traumatic lacerations repaired over a four-year period was conducted. Structured closed-question data sheets were prospectively completed at the time of laceration repair and suture removal. Infection was determined at the time of suture removal. Multivariate modeling was used to determine the adjusted odds ratio (OR) of infection.

RESULTS

Five thousand five hundred twenty-one patients were enrolled; 195 patients developed an infection (3.5%). An increased likelihood of wound infection was associated with age (adjusted OR per year, 1.01; 95% CI = 1.0 to 1.02); history of diabetes mellitus (adjusted OR 6.7; 95% CI = 1.7 to 26.4); laceration width (adjusted OR 1.05 per mm; 95% CI = 1.02 to 1.08); and presence of foreign body (adjusted OR 2.6; 95% CI = 1.3 to 5.2). Laceration location on the head/neck was associated with a decreased risk of infection (adjusted OR 0.28; 95% CI = 0.18 to 0.45).

CONCLUSIONS

Both patient and wound characteristics of traumatic lacerations have an influence on the likelihood of infection. This knowledge may be valuable for determining whether various methods of wound cleansing, debridement, and repair can improve the outcome of patients with traumatic lacerations.

Molecular pathobiology of the human lipoprotein lipase gene

Lipoprotein lipase (LPL; E.C. 3.1.1.34) is a key enzyme in the metabolism of lipids. Many diseases, including obesity, coronary heart disease, chylomicronemia (pancreatitis), and atherosclerosis, appear to be directly or indirectly related to abnormalities in LPL function. Human LPL is a member of a superfamily of lipases that includes hepatic lipase and pancreatic lipase. These lipases are characterized by extensive homology, both at the level of the gene and the mature protein, suggesting that they have a common evolutionary origin. A large number of natural mutations have been discovered in the human LPL gene, which are located at different sites in the gene and affect different functions of the mature protein. There is a high prevalence of two of these mutations (207 and 188) in the Province of Québec, and one of them (207) is almost exclusive to the French-Canadian population. A study of these and other naturally occurring mutant LPL molecules, as well as those created in vitro by site-directed mutagenesis, indicate that the sequence of LPL is organized into multiple structural and functional units that act in concert in the normal enzyme. In this review, we discuss the interrelationships of LPL structure and its function, the molecular etiology of abnormal LPL in humans, and the clinical and therapeutic aspects of LPL deficiency.

Infectious problems in elective surgery of the alimentary tract: the influence of pre-operative factors. The Norwegian Gastro-Intestinal Group (NORGAS)

The influence of some pre-operative factors on infectious complications after elective abdominal surgery was investigated in a prospective multi-centre study of 1537 patients in surgical departments regularly using a standardized prophylactic antibiotic regimen. A total of 1101 patients received 1600 mg tinidazole plus 400 mg doxycycline intravenously 1-hour pre-operatively. Analysis of the results showed that increasing age, malignancy, risk factors noted by the surgeon before the surgical procedure, and discrepancies between assumed disease and peri-operative findings were associated with significantly more post-operative complications, but not more infectious complications related to peri-operative contamination. Pre-operative hospital stay did not influence the infection rate provided that prophylaxis was given.

Infectious problems after elective surgery of the alimentary tract: the influence of peri-operative factors. The Norwegian Gastro-Intestinal Group (NORGAS)

A prospective multi-centre study was carried out on 1537 patients to investigate the influence of some peri-operative factors on the infectious complications after elective abdominal surgery in surgical departments where a standardized prophylactic antibiotic regimen is used regularly. The antibiotic regimen consisted of 1600 mg tinidazole and 400 mg doxycycline given intravenously 1-hour preoperatively. The results showed that total gastrectomy seemed to give higher infection rates than other gastroduodenal procedures. Low anterior and abdomino-perineal rectal resections were followed by more infectious complications than colonic resections, but this difference was significant only due to the perineal wound infections and failures of the low anterior anastomosis. Prolonged operation time was followed by increased number of infectious complications only when prophylaxis was not given. Blood transfusions led to a highly significant increase in infectious complications. Peri-operative surgical complications, splenectomy and stoma formation did not influence post-operative infectious complications.

Surgical infections--the general surgeon's perspective. Defining the problem, seeking solutions

Infection has been historically the greatest threat to patients undergoing surgery, but with effective surveillance programs, the risk of surgical infection can be markedly reduced. An effective approach to infection control involves attention to the triad complex of infection--asepsis (keeping bacteria below the "critical inoculum"), antisepsis (disciplined use of antibiotics), and host defense mechanisms (altering factors that reduce immunity). Several large studies indicate a national trend toward decreased wound infection rates. This trend is probably attributable to a wide acceptance of surveillance programs, shorter length of hospitalization, and better use of antibiotic therapy.

Renal transplant wound infection: the value of prophylactic antibiotic treatment

The incidence of wound infection after 310 renal transplant operations was examined. Among the 78 recipients not given prophylactic antibiotic therapy infection of the transplant wound occurred in 25.6%. Among the 232 patients given prophylactic therapy, with narrow-spectrum antibiotic (cloxacillin), wound infection occurred in only 7.8%. This statistically significant difference in incidence was ascribed to a less frequent occurrence of staphylococcal wound infection in the group of patients receiving antibiotic therapy than in the group not so treated. The presence of wound haematoma, which increased the risk of wound infection, was the only factor predisposing to such infection in this patient series.

Chylomicronemia syndrome. Interaction of genetic and acquired hypertriglyceridemia

Chylomicrons accumulating in plasma obtained after an overnight fast are always abnormal and can be detected in association with triglyceride levels above 1000 mg per dl. The chylomicronemia syndrome is associated with marked hypertriglyceridemia (plasma triglyceride level above 2000 mg per dl), abdominal pain or pancreatitis, eruptive xanthomata, lipemia retinalis, dyspnea, mental aberrations, and other minor findings. The marked hypertriglyceridemia is usually due to the interaction of a common familial form of hypertriglyceridemia and a common acquired form of hypertriglyceridemia secondary to another disease, drug, or alcohol. Rarely, genetic abnormalities in lipoprotein lipase are the cause of the marked hypertriglyceridemia. Therapy that successfully lowers plasma triglyceride levels is associated with clearing of the symptoms and signs of the chylomicronemia syndrome and prevention of its recurrence.

Postoperative deep venous thrombosis and infectious complications. A clinical study of patients undergoing colo-rectal surgery

The connection between deep venous thrombosis (DVT) and postoperative infectious complications (PIC) was studied in 170 patients (mean age 65.7 and 40--86 years) who had undergone open large bowel or rectal surgery. DVT was diagnosed by the 125I-fibrinogen method. DVT of the legs was found in 36 patients. In 58 patients with PIC the frequency of DVT in 41 patients receiving low-dose heparin was 29% and in 17 patients without heparin prophylaxis 71% (P less than 0.01). In 112 patients without infection the frequency of DVT in 98 patients receiving low-dose heparin was 12% and 14 patients without heparin prophylaxis 7%. The frequency of DVT was significantly lower in patients without infection compared to those with PIC (P less than 0.001). Serious DVTs were more common in patients with PIC compared to those without PIC (P less than 0.05). It is concluded that infections after open large bowel and rectal surgery is an important risk factor for the development of DVT. Low-dose heparin significantly reduces the frequency of DVT in infected patients.

Fibrinogen catabolism in patients with postoperative infectious complications

The biological half-life (TB) of 125I-fibrinogen was studied in 21 surgical patients, using a precordial counting technique. TB was calculated for the first 4 postoperative days (first phase) and for the 5th to 10th days (second phase). Daily calculations of TB were undertaken in 15 patients. In patients with a normal postoperative course, TB was 2.31 days (first phase) and 3.80 days (second phase). In patients with a postoperative infectious complication (PIC), TB was 1.74 days (first phase) and 2.21 days (second phase), which was significantly shorter than corresponding values in patients with normal postoperative course. The mean of the daily values of TB was significantly shorter in the second phase in patients with PICs compared to those with a normal postoperative course. Co-variance analysis of daily TB in the first and second phases showed no significant difference in 25/30 phases (83%). It is suggested that TB of 125I-fibrinogen can be used as a complement to the clinical diagnosis of PIC. Further studies are desirable to confirm the method.

A nonpancreatic source of the proteolytic-enzyme amidase and bacteriology in experimental acute pancreatitis

In previous studies of human and experimental acute pancreatitis, three main assumptions have been made. First, that the disease is due to activation of pancreatic proteolytic enzymes in the pancreas with resulting "autodigestion" of the gland. Second, that interstitial pancreatitis is a mild form of hemorrhagic pancreatitis into which it may progress, and third, that bacteria play little part, if any, in the initiation of the disease. These assumptions are now questioned. In the present study in dogs, levels of proteolytic enzymes in blood, thoracicduct lymph and peritoneal fluid were measured using benzoylarginine amide. Raised levels of amidase were found in hemorrhagic, but not with interstitial, pancreatitis, and biochemical examination of amidase suggested it was not a pancreatic protease, but with its broad specificity and stability derived from bacteria. Addition of antibiotic to the blind duodenal loop in hemorrhagic pancreatitis reduced the level of blood amidase, but Trasylol given intravenously did not, nor did it inhibit amidase in vitro. In all animals, histological examination was made of the pancreas at time of death. On bacteriology, it is concluded that experimental interstitial pancreatitis results from damage to the pancreatic duct system without infection, and haemorrhagic pancreatitis mainly from reflux of bacteria into the pancreatic ducts from the duodenum. Only bacteria such as Escherichia coli and Clostridium welchii that produce proteolytic enzymes and cytotoxins appear to be able to cause haemorrhagic pancreatitis, and these bacteria may explain the release of vasoactive polypeptides and the vascular effects. In hemorrhagic pancreatitis such bacteria were found in the pancreas, but none in interstitial pancreatitis. Evidence is given to suggest that pancreatic proteolytic enzymes are unlikely to cause the cell necrosis which is a pathological feature of hemorrhagic pancreatitis, and that "autodigestion" is likewise unlikely to be a cause of this condition. An extrapancreatic source of proteolytic enzymes from bacteria is now suggested in haemorrhagic pancreatitis, and more attention to bacteriology in human acute pancreatitis is urgently needed. Amidase levels were highest in peritoneal fluid, suggesting a rationale for peritoneal lavage in the treatment of acute pancreatitis, and it is unlikely that Trasylol can give any benefit. The assessment of treatment of acute pancreatitis will be unsatisfactory as long as the proportion of haemorrhagic to interstitial pancreatitis in any series is not known accurately.

An evaluation of a post-operative vacuum drainage system

The effectiveness of a plastic bottle vacuum drainage system ('Steritex vacu-drain') was evaluated in 50 randomly selected patients undergoing major surgery. The incidence of post-operative wound infection was 6%. The drainage system was found to be effective and acceptable to both patients and personnel involved in its management.

Bacteria in hip surgery. A study of routine aerobic and anaerobic cultivation from skin and closed suction wound drains

One hundred and seven patients with closed suction wound drains after hip surgery were investigated with regard to bacteria in the drain. In one-third of the cases bacterial contamination of the wound was found. In more than half the total number of cases the bacteria in the wound were not identical with those found on the skin, either pre- or post-operatively. Anaerobe bacteria occurred only in one case. Penicillin administration considerably reduced the frequency of positive cultures. These findings support the prophylactic use of antibiotics in the prevention of late infections in endoprosthesis operations even when the early infection rate is satisfactorily low.