Treating diabetes with islet transplantation: lessons from the past decade in Lille

Type 1 diabetes (T1D) is due to the loss of both beta-cell insulin secretion and glucose sensing, leading to glucose variability and a lack of predictability, a daily issue for patients. Guidelines for the treatment of T1D have become stricter as results from the Diabetes Control and Complications Trial (DCCT) demonstrated the close relationship between microangiopathy and HbA1c levels. In this regard, glucometers, ambulatory continuous glucose monitoring, and subcutaneous and intraperitoneal pumps have been major developments in the management of glucose imbalance. Besides this technological approach, islet transplantation (IT) has emerged as an acceptable safe procedure with results that continue to improve. Research in the last decade of the 20th century focused on the feasibility of islet isolation and transplantation and, since 2000, the success and reproducibility of the Edmonton protocol have been proven, and the mid-term (5-year) benefit-risk ratio evaluated. Currently, a 5-year 50% rate of insulin independence can be expected, with stabilization of microangiopathy and macroangiopathy, but the possible side-effects of immunosuppressants, limited availability of islets and still limited duration of insulin independence restrict the procedure to cases of brittle diabetes in patients who are not overweight or have no associated insulin resistance. However, various prognostic factors have been identified that may extend islet graft survival and reduce the number of islet injections required; these include graft quality, autoimmunity, immunosuppressant regimen and non-specific inflammatory reactions. Finally, alternative injection sites and unlimited sources of islets are likely to make IT a routine procedure in the future.

[Incidence of biological tests requested outside of written medical prescriptions in digestive surgical intensive care unit]

OBJECTIVES

Realization of biological tests in intensive care unit requires a written medical prescription. Requests of biological tests outside written medical prescription are sometimes observed. The aim of the survey was to evaluate their incidence and the reasons of these practices.

MATERIALS AND METHODS

The study was realized on a 14 days-period in a 8 beds intensive care unit of digestive surgery, in real situation and anyone was informed of the study. Nineteen patients were enrolled during the period of the study.

RESULTS

A request of biological tests outside written medical prescription was found in 78% of requests of tests (89/114). The incidence of requests of biological tests outside written medical prescription was 27%. Several reasons could explain these practices.

CONCLUSION

This study confirms that there is a high frequency of requests of biological tests outside written medical prescription and that several reasons could explain these practices in intensive care unit.

[Monitoring expired oxygen fraction in preoxygenation of patients with chronic obstructive pulmonary disease]

OBJECTIVES

To compare the rate of preoxygenation before induction of anesthesia in patients with no lung disease and in patients with chronic obstructive pulmonary disease (COPD).

PATIENTS AND METHODS

End-tidal fractional oxygen concentration (FEO2) was monitored using a paramagnetic oxygen analyzer, during a 5 minute-period of preoxygenation (tidal breathing of 100% oxygen) in 16 control patients (control group) and in 15 patients with COPD. COPD was defined and its severity was characterized by clinical criteria and by respiratory functional tests. FEO2 increase was compared between groups using Anova.

RESULTS

The increase in FEO2 was slower in the COPD group than in control group (p < 0.05). After 2 and 3 minutes of preoxygenation, FEO2 was significantly lower in COPD group as compared to control group, but was not different at 5 minutes. Mean time to reach a FEO2 equal to 0.90 was significantly longer in COPD than in control group (COPD: 261 +/- 130 s; control: 165 +/- 90 s, p < 0.05). SpO2 measured during room air breathing was moderately lower in COPD group, but this difference was no more significant after 30 s of preoxygenation (SpO2 after 30 s: control: 98.8 +/- 1.0%; COPD: 98.2 +/- 1.9%, NS).

CONCLUSION

These results suggest that preoxygenation monitoring may be useful in patients with COPD, to ensure adequate preoxygenation is achieved.

End-tidal oxygraphy during pre-oxygenation in patients with severe diffuse emphysema

We hypothetised that the rate of pre-oxygenation could be altered by the increase in lung volume and airflow obstruction observed in emphysema. End-tidal oxygen concentration was monitored, using a paramagnetic oxygen analyser, during 10-min pre-oxygenation (tidal breathing of 100% oxygen) in 10 normal patients and in 10 patients with severe diffuse emphysema documented by computerised tomography. Emphysema was characterised by an important increase in functional residual capacity of the lungs [190 (23)% of predicted values] and a decrease in expiratory flow. The increase in end-tidal oxygen concentration was slower in the emphysema group than in the control group (p = 0.0024). After 3 and 5 min of pre-oxygenation, the end-tidal fractional oxygen concentration was significantly lower in the emphysema group than the control group [mean (SD); value at 3 min: emphysema: 0.83 (0.06) vs. control: 0.91 (0.02), p = 0.0005]. Individual values of end-tidal oxygen concentration measured after 3, 5 and 10 min of pre-oxygenation were negatively correlated with functional residual capacity in the emphysema group, whereas no such correlation was found in the control group. These results suggest that pre-oxygenation should be monitored in patients with diffuse emphysema to ensure that adequate pre-oxygenation is achieved.

Placebo-controlled study of inhaled nitric oxide to treat hypoxaemia during one-lung ventilation

The aim of this prospective, placebo-controlled study was to assess if unilaterally inhaled nitric oxide 20 ppm could treat hypoxaemia during one-lung ventilation. Sixty patients undergoing pulmonary resection using a lateral thoracotomy were allocated randomly to a control or nitric oxide group (NO group). During one-lung ventilation in the lateral decubitus position, the lungs were ventilated mechanically with 90% oxygen--10% nitrogen. After randomization, if PaO2 decreased to less than 9.3 kPa during one-lung ventilation, nitric oxide 20 ppm or nitrogen was added to the inspired gas. The criterion for treatment efficacy was an increase in PaO2 to greater than 9.3 kPa after gas administration. Eight patients in the control group and eight in group NO experienced hypoxaemia during one-lung ventilation. PaO2 was not significantly different in the two groups at the time of gas administration (control group mean 8.0 (SD 0.6) kPa; NO group 8.5 (0.5) kPa). The efficacy criterion was reached in two of eight patients in the control and NO groups. The results of this study showed that inhaled nitric oxide 20 ppm, administered in the dependent lung, was not superior to nitrogen in the treatment of hypoxaemia during one-lung ventilation. Nitric oxide should not be recommended as an alternative to conventional management of hypoxaemia in this condition.

[Angina pectoris and hypertension]

Angina pectoris results from an insufficient flow of oxygen to the myocardia cells. It is not an unusual complication in the dental office, the most frequent factors that trigger angina are: -stress, -pain, -exercise. The treatment consists in providing oxygen and vasodilators. Hypertension is characterized by an increase in the diastolic arterial blood pressure over 120 mmHg and by other clinical manifestations. Stress, pain, and exercise are the most frequent factors responsible for hypertensive disease. Hypertensive disease can lead to various complications ranging from a headache to myocardial infarct or hemiplegia. Treatment consists of different types of vasodilators.

[Physiopathology of respiratory accidents]

The physiopathology of respiratory accident will be discussed after a short summary of the respiratory system anatomy and its function at rest. The second part of this article will review the main reasons for respiratory deficiencies which are classified in four chapters: attack of the diaphragm attack of the wall attack of the respiratory tracts attack of the alveolo-capillary exchange The principal consequences, hypoxia and hypercapnia will be seen in the conclusion.

[Absence of clinical and biological manifestations after massive absorption of nitulamide]

Nitulamide (ANANDRON (R] is an antiandrogen used as an adjuvant therapy in the treatment of advanced prostatic cancer. The effects of ingestion of high doses of nitulamide has not been so far reported. A 79 years old man was admitted 2 hours after the ingestion of 13 g of nitulamide (170 mg/kg or 43 times the therapeutic dose), in a suicide attempt. He was receiving nitulamide 300 mg/day for two weeks. On admission, he underwent immediately gastric lavage, followed by administration of oral activated charcoal and received an intravenous infusion of glucose in balanced salt solution. During the first 12 hours, the patient presented with moderate vomiting and diarrhoea. There was no change in the following parameters: blood cell count, plasma electrolytes, serum transaminases and serum bilirubin, arterial blood gases, plasma cortisol value, as compared to the pre-treatment values. Chest X ray was unchanged. Plasma concentrations were measured 2 hours, 3 hours, 12 hours, 24 hours, 48 hours and 72 hours after ingestion. The initial level reached 6 times the normal therapeutic range, then fell to 3.5 times at the 72th hour. The patient recovered rapidly and was discharged on the 4th day. Biologic parameters were controlled on 4th, 9th, 30th day and remained unchanged. Treatment was started again on the 30th day with nitulamide 150 mg/day. We did not notice any side effect previously described in daily administration of nitulamide: anemia, rise in serum transaminases, interstitial pneumopathy.