Total pancreatectomy with islet cell transplantation vs intrathecal narcotic pump infusion for pain control in chronic pancreatitis

AIM: To evaluate pain control in chronic pancreatitis patients who underwent total pancreatectomy with islet cell transplantation or intrathecal narcotic pump infusion.METHODS: We recognized 13 patients who underwent intrathecal narcotic pump(ITNP) infusion and 57 patients who underwent total pancreatectomy with autologous islet cell transplantation(TP + ICT) for chronic pancreatitis(CP) pain control between 1998 and 2008 at Indiana University Hospital. All patients had already failed multiple other modalities for pain control and the decision to proceed with either intervention was made at the discretion of the patients and their treating physicians. All patients were evaluated retrospectively using a questionnaire inquiring about their pain control(using a 0-10 pain scale), daily narcotic dose usage, and hospital admission days for pain control before each intervention and during their last follow-up. RESULTS: All 13 ITNP patients and 30 available TP + ICT patients were evaluated. The mean age was approximately 40 years in both groups. The median duration of pain before intervention was 6 years and 7 years in the ITNP and TP + ICT groups, respectively. The median pain score dropped from 8 to 2.5(on a scale of 0-10) in both groups on their last follow up. The median daily dose of narcotics also decreased from 393 mg equivalent of morphine sulfate to 8 mg in the ITNP group and from 300 mg to 40 mg in the TP + ICT group. No patient had diabetes mellitus(DM) before either procedure whereas 85% of those who underwent pancreatectomy were insulin dependent on their last evaluation despite ICT. CONCLUSION: ITNP and TP + ICT are comparable for pain control in patients with CP however with high incidence of DM among those who underwent TP + ICT. Prospective comparative studies and longer follow up are needed to better define treatment outcomes.

Does carrier fluid reduce low flow drug infusion error from syringe size?

BACKGROUND Critically ill neonates and pediatric patients commonly require multiple low flow infusions.Volume limitations are imposed by small body habitus and comorbidities like cardiopulmonary disease,renal failure,or fluid overload.Vascular access is limited by diminutive veins.Maintenance fluids or parenteral nutrition in conjunction with actively titrated infusions such as insulin,fentanyl,prostaglandins,inotropes and vasopressors may necessitate simultaneous infusions using a single lumen to maintain vascular catheter patency.This requirement for multiple titratable infusions requires concentrated medications at low flows,rather than more dilute drugs at higher flows that in combination may volume overload small infants.AIM To determine whether carrier fluid reduces variability that variability of low flow drug infusions is proportional to syringe size in pediatric critical care.METHODS We assessed concentrations of orange“drug”in a 0.2 mL/h low flow clinical model with blue dyed carrier fluid at 5 mL/h,using 3-,10-,or 60-mL syringes.A graduated volumetric pipette was used to measure total flow.Mean time to target concentration was 30,21,and 46 min in 3-,10-,and 60-mL syringes,respectively(P=0.42).After achieving target concentration,more dilute drug was delivered by 60-mL(P<0.001)and 10-mL syringes(P=0.04)compared to 3-mL syringes.Drug overdoses were observed during the initial 45 min of infusion in 10-and 60-mL syringes.Total volumes infused after target concentration were less in the 60-mL condition compared to 3-mL(P<0.01)and 10-mL(P<0.001)syringes.RESULTS Linear mixed effects models demonstrated lesser delivered drug concentrations in the initial 30 min by 3-mL compared to 10-and 60-mL syringes(P=0.005 and P<0.001,respectively)but greater drug concentrations and total infused drug in the subsequent 30-60 and 60-90 min intervals with the 3-and 10-mL compared to 60-mL syringes.CONCLUSION With carrier fluid,larger syringes were associated with significantly less drug delivery,less total volume delivered,and other flow problems in our low flow drug model.Carrier fluid should not be used to compensate for inappropriately large syringes in critical low flow drug infusions.

Insights on liver-directed surgical innovations, targeted therapies, and immunotherapy for biliary tract cancer: navigating the new European Society for Medical Oncology (ESMO) Clinical Practice Guidelines

Cancers of the bile duct,including gallbladder cancer,extrahepatic cholangiocarcinoma,hilar and intrahepatic cholangiocarcinoma,present a significant treatment challenge.Characterized by their notorious difficulty to diagnose or biopsy,intricate anatomical locations and diverse clinical presentations,these malignancies collectively contribute to a significant burden on global health.The epidemiology of bile duct cancers reveals worldwide variations in incidence,prevalence,and mortality rates,emphasizing the need for a nuanced understanding of each subtype and the local environmental etiologies.Challenges in early diagnosis further compound the complexity of managing these cancers,often leading to advanced stage at the time of detection and treatment delays.Surgery remains the cornerstone of curative-intent treatment of bile duct cancers,yet the rate of recurrence and metastases underscores the importance of comprehensive multidisciplinary therapeutic strategies.Pivotal randomized clinical trials have been performed;however,they have been challenged by the lack of active agents,a limited number of accrued patients,and a grouping of all patients together regardless of where in the biliary tract the tumor originates.This has resulted in variations in treatment strategies and multiple treatment options that range from immunotherapy to radiation to hepatic artery infusion therapy(more on this later).A greater understanding of the mutational landscape of biliary tract cancers has resulted in optimism around appropriately targeted agents and combination immunotherapies.Yet,many of these regimens await robust outcomes data,and it is questionable if they significantly move the needle forward to improve overall survival.Thus now,more than ever,there is a need for updated treatment guidelines.