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Objective: The aim of this study was to evaluate sequential hypothermic and normothermic machine perfusion (NMP) as a tool to resuscitate and assess viability of initially declined donor livers to enable safe transplantation. Summary Background Data: Machine perfusion is increasingly used to resuscitate and test the function of donor livers. Although (dual) hypothermic oxygenated machine perfusion ([D]HOPE) resuscitates livers after cold storage, NMP enables assessment of hepatobiliary function. Methods: In a prospective clinical trial, nationwide declined livers were subjected to ex situ NMP (viability assessment phase), preceded by 1-hour DHOPE (resuscitation phase) and 1 hour of controlled oxygenated rewarming (COR), using a perfusion fluid containing an hemoglobin-based oxygen carrier. During the first 2.5 hours of NMP, hepatobiliary viability was assessed, using predefined criteria: perfusate lactate <1.7 mmol/L, pH 7.35 to 7.45, bile production >10mL, and bile pH >7.45. Livers meeting all criteria were accepted for transplantation. Primary endpoint was 3-month graft survival. Results: Sixteen livers underwent DHOPE--COR--NMP. All livers were from donors after circulatory death, with median age of 63 (range 42-82) years and median Eurotransplant donor risk index of 2.82. During NMP, all livers cleared lactate and produced sufficient bile volume, but in 5 livers bile pH remained <7.45. The 11 (69%) livers that met all viability criteria were successfully transplanted, with 100% patient and graft survival at 3 and 6 months. Introduction of DHOPE--COR--NMP increased the number of deceased donor liver transplants by 20%. Conclusions: Sequential DHOPE--COR--NMP enabled resuscitation and safe selection of initially declined high-risk donor livers, thereby increasing the number of transplantable livers by 20%. Trial registration: www.trialregister.nl; NTR5972. [ABSTRACT FROM AUTHOR]

The article discusses a study which determined the prognostic value of myocardial blush grade (MBG) during primary percutaneous coronary intervention (PCI) in consecutive patients with ST-elevation myocardial infarction (STEMI). The study included patients with STEMI who underwent primary PCI between January 2004 and July 2008. Study authors concluded that MBG scored by the operator during primary PCI can be used as a prognostic factor for 1-year all cause mortality in patients with STEMI.

The article presents a study which estimates the mortality risk to patients with trauma. Result shows that emergency trauma score (EMTRAS) from the emergency room predicts mortality. It notes that knowledge of the anatomical injuries are not necessary. It also suggests that determination of EMTRAS will inform caregivers on the severity on the condition of patients with trauma.

The authors comment on a study published within the issue which investigated the overall mortality at the intensive care unit (ICU) comparing patients with and without diabetes aimed to test the hypothesis that the apparent protective effects of diabetes may be mediated by medication administered to patients with diabetes. The author finds that the inclusion of a history of cardiovascular disease within the definition of cardiac overload and excluding acute lung injury (ALI) as suboptimal.

Background: Preconditioning of donor livers before organ retrieval may improve organ quality after transplantation. We investigated whether preconditioning with metformin reduces preservation injury and improves hepatobiliary function in rat donor livers during ex situ normothermic machine perfusion (NMP) and after orthotopic liver transplantation., Methods: Lewis rats were administered metformin via oral gavage, after which a donor hepatectomy was performed followed by a standardized cold storage period of 4 hours. Graft assessment was performed using NMP via double perfusion of the hepatic artery and portal vein. In an additional experiment, rat donor livers preconditioned with metformin were stored on ice for 4 hours and transplanted to confirm postoperative liver function and survival. Data were analyzed and compared with sham-fed controls., Results: Graft assessment using NMP confirmed that preconditioning significantly improved ATP production, markers for hepatobiliary function (total bile production, biliary bilirubin, and bicarbonate), and significantly lowered levels of lactate, glucose, and apoptosis. After orthotopic liver transplantation, metformin preconditioning significantly reduced transaminase levels., Conclusions: Preconditioning with metformin lowers hepatobiliary injury and improves hepatobiliary function in an in situ and ex situ model of rat donor liver transplantation.

Background: The time distribution of injuries is not random. To assess the potential impact of weather and the phase of the moon on accidents, adjustment for known periodic and nonperiodic factors may be important. We compared the incidence of injuries with quantitative and qualitative weather variables as well as the lunar cycle, after correction for calendar and holiday-related factors., Methods: We extracted the daily number of trauma patients treated at the emergency department over 36 years (1970-2005) from the trauma database of our regional hospital. For each patient, age, sex, cause of injury, and severity of injury were recorded. This was combined with daily meteorological data including temperature, precipitation, sunshine, humidity, air pressure, and wind as well as the lunar phase. We also related the rate of change of these parameters with the incidence of injuries. A qualitative weather variable derived from temperature, sunshine duration, and precipitation was defined as bad, normal, or good. Periodicities were adjusted for with Poisson regression spline fitting analysis., Results: Several weather variables were related with the number of injuries. For most of these, better weather conditions were associated with an increase in trauma incidence. Good weather, which was present on 16.5% of the days, resulted in 10.1% (9.3-11.4 95% CI) more traumas compared with normal weather. Full moon was associated with a 2.1% (1.1-3.0 95% CI) lower trauma incidence than new moon., Conclusions: Better weather conditions contribute to an increased incidence of trauma. Full moon is associated with a slightly lower trauma incidence.

Background: Increased production of red blood cells (RBCs) should be reflected by increased reticulocyte counts (RC). With the introduction of modern fully automated measurements of RC, the recovery of hemoglobin (Hb) after blood loss might be assessed earlier. We investigated the temporal relation of Hb and RC in trauma patients., Methods: Over a 10-month period, all patients with trauma admitted to our University Medical Center were analyzed. Both Hb (reference values: males, 14.0-17.1 g/dL; females, 12.1-15.9 g/dL) and RC (8-26 promille) were determined with a Sysmex XE-2100 analyzer. RBC transfusions were administered in otherwise healthy patients below an Hb threshold of 6.9 g/dL. Hb and RC were analyzed for a maximum of 30 days posttrauma and related in multivariate analysis to age, sex, and comorbidity., Results: Two hundred and forty-one patients (age 52 years +/- 21 years) were studied. In 28 patients (12%), one or more RBCs were administered with a mean of 2.2 RBCs (range, 1-4). Hb decreased to 10.9 g/dL +/- 2.1 g/dL on day 3. RC rose from 16 +/- 11 at admission to 38 promille +/- 21 promille on day 13 (p < 0.0001). Nadir Hb values and maximum RC values were inversely related according to univariate analysis (Pearson R = -0.62, p < 0.001). In multivariate analysis, Hb remained the only significant determinant of RC (R = 0.64, p < 0.001)., Conclusions: Hb and RC are clearly related in trauma patients. Measuring RC may be helpful in predicting the rise of Hb after acute blood loss.

Background: The care for trauma patients has undergone major changes during the last decades. Additionally, many injury prevention measures have been established. The objective of these efforts was to reduce the number of traumatic incidents and to reduce mortality and morbidity in injured patients. The aim of our study was to assess how these measures and improved care have altered trauma mechanisms, occurrence of injuries, treatment, and outcome in the trauma population treated at our trauma center., Methods: Two cohorts of trauma patients with an Injury Severity Score >15, treated at the University Medical Center Groningen were compared. The first cohort was treated from 1985 to 1990, the second cohort from September 2002 to January 2005., Results: The annual mean number of severely injured patients increased by 76%. Fourteen percent more patients had sustained an injury at home. The mean age increased from 33 +/- 22 years to 41 +/- 23 years. The presence of severe head and neck injuries in the patients increased from 62% to 73%. Inhospital mortality remained unchanged at 25%. The outcome of survivors improved; 67% of patients made a moderate or good recovery versus 40% almost 20 years ago., Conclusions: Striking are the consequences of the aging of the Dutch population: an almost 10-year increase in mean age and a rise in severe head and neck injuries in the population treated at our trauma center. The unchanged mortality and improved outcome of survivors represented the enhanced trauma care.

Background: Estimating blood loss in trauma patients usually involves the determination of hematocrit (Ht) or hemoglobin (Hb). However, in trauma patients, a poorly substantiated habit exists to determine both Ht and Hb in assessing acute blood loss. This suggests that Ht and Hb provide different information. Moreover, a survey of the literature showed a significant association of the subject trauma with the use of Ht. We investigated whether Ht and Hb differ in trauma patients., Methods: Trauma patients with an Injury Severity Score>15 admitted from 1996 to 2004 to the University Medical Center Groningen were analyzed. All blood samples obtained during the first 7 days postinjury in which both Ht and Hb were determined were studied. Ht and Hb were measured with a Coulter Counter. The relation between Ht and Hb was analyzed with linear regression. The potential effect of hemolysis was studied by analyzing lactate dehydrogenase levels., Results: In 671 patients 2,461 paired Ht levels and Hb levels were obtained. The mean Ht was 30.9%+/-6.9% (interquartile range 25.8%-35.8%). The mean concentration of Hb was 10.4+/-2.3 g/dL (interquartile range 8.7-12.1 g/dL). Ht and Hb had a Pearson's R of 0.99 and the following relations applied: Ht (%)=2.953xHb (g/dL) or Hb (g/dL)=0.334xHt (%). Lactate dehydrogenase was not related with Ht and Hb, indicating hemolysis was not relevant., Conclusions: In a large series of trauma patients, Ht and Hb behaved as identical parameters. The idea that Ht is different from or even superior to Hb is a misconception. There is no reason for determining both Ht and Hb in trauma patients.

Background: Acute hyperglycemia is associated with adverse outcome in critically ill patients. Glucose control with insulin improves outcome in surgical intensive care unit (SICU) patients, but the effect in trauma patients is unknown. We investigated hyperglycemia and outcome in SICU patients with and without trauma., Methods: A 12-year retrospective study was performed at a 12-bed SICU. We collected the reason for admission, Injury Severity Scores (ISS), and 30-day mortality rates. Glucose measurements were used to calculate the hyperglycemic index (HGI), a measure indicative of overall hyperglycemia during the entire SICU stay., Results: In all, 5234 nontrauma and 865 trauma patients were studied. Trauma patients were younger, more frequently male, and had both lower median admission glucose (123 versus 133 mg/dL) and HGI levels (8.9 vs. 18.4 mg/dL) than nontrauma patients (p < 0.001). Mortality was 12% in both groups. Area under the receiver-operator characteristic for HGI and mortality was 0.76 for trauma patients and 0.58 for nontrauma patients (p < 0.001). In multivariate analysis, HGI correlated better with mortality in trauma patients than in nontrauma patients (p < 0.001). Head-injury and nonhead-injury trauma patients showed similar glucose levels and relation between glucose and mortality., Conclusions: The relation of hyperglycemia and mortality is more pronounced in trauma patients than in SICU patients admitted for other reasons. The different behavior of hyperglycemia in these patients underscores the need for evaluation of intensive insulin therapy in these patients.