Prostacyclin in trauma patients with hemorrhagic shock: A randomized clinical trial.

BACKGROUND: A main cause of trauma morbidity and mortality is multiple-organ failure, and endotheliopathy has been implicated. Pilot studies indicate that low-dose prostacyclin improves endothelial functionality in critically ill patients, suggesting that this intervention may improve trauma patient outcome. METHODS: We conducted a multicenter, randomized, blinded, clinical investigator-initiated trial in 229 trauma patients with hemorrhagic shock who were randomized 1:1 to 72 hours infusion of the prostacyclin analog iloprost (1 ng/kg/min) or placebo. The primary outcome was the number of intensive care unit (ICU)-free days alive within 28 days of admission. Secondary outcomes included 28-day all-cause mortality and hospital length of stay. RESULTS: The mean number of ICU-free days alive within 28 days was 15.64 days in the iloprost group versus 13.99 days in the placebo group (adjusted mean difference, -1.63 days [95% confidence interval (CI), -4.64 to 1.38 days]; p = 0.28). The 28-day mortality was 18.8% in the iloprost group versus 19.6% in the placebo group (odds ratio, 1.01 [95% CI, 0.51-2.0]; p = 0.97). The mean hospital length of stay was 19.96 days in the iloprost group versus 27.32 days in the placebo group (adjusted mean difference, 7.84 days [95% CI, 1.66-14.02 days], p = 0.01). CONCLUSION: Iloprost did not result in a statistically significant increase in the number of ICU-free days alive within 28 days of admission, whereas it was safe and a statistically significant reduction in hospital length of stay was observed. Further research on prostacyclin in shocked trauma patients is warranted. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level II.

Effect of PTH treatment on bone healing in insufficiency fractures of the pelvis: a systematic review.

The aging of our society is associated with an increasing number of insufficiency fractures of the pelvis and the current standard of care is pain control and early mobilization. The aim of this study was to explore whether parathyroid hormone (PTH) treatment can support bone healing in these patients.We conducted a systematic review searching the databases PubMed, Embase and Cochrane. Our primary outcome was fracture healing, secondary outcome measures comprised pain, mobility and patient-reported outcome measures (PROMs).Eight articles were included in the qualitative synthesis, of which two were included in a meta-analysis. However, only three studies were comparative including one randomized controlled trial. Fracture healing and reported pain were assessed after eight weeks, and were significantly improved in the group being treated with PTH (p < 0.01) in the meta-analysis. All articles described a positive effect for PTH on fracture healing and pain.Our systematic review indicates that there is a positive effect of PTH treatment on healing and pain in patients with insufficiency fracture in the pelvic ring, but further research is necessary. Cite this article: EFORT Open Rev 2021;6:9-14. DOI: 10.1302/2058-5241.6.200029.

Efficacy and safety of iloprost in trauma patients with haemorrhagic shock-induced endotheliopathy-Protocol for the multicentre randomized, placebo-controlled, blinded, investigator-initiated shine-trauma trial.

BACKGROUND: Traumatic injury accounts for 800 000 deaths in the European Union annually. The main causes of deaths in trauma patients are exsanguination and multiple organ failure (MOF). We have studied >1000 trauma patients and identified shock-induced endotheliopathy (SHINE), the pathophysiological mechanism responsible for MOF and high mortality. Pilot studies indicate that low-dose iloprost (1 ng/kg/min) improves endothelial functionality in critically ill patients suggesting this intervention may improve patient outcome in traumatic SHINE. MATERIAL AND METHODS: This is a multicentre, randomized, blinded clinical investigator-initiated phase 2B trial in trauma patients with haemorrhagic shock-induced endotheliopathy. Patients are randomized 1:1 to 72 hours infusion of iloprost 1 ng/kg/min or Placebo (equal volume of saline). A total of 220 trauma patients will be included. The primary endpoint is the number of intensive care unit (ICU)-free days, within 28 days of admission. Secondary endpoints include 28- and 90-day all-cause mortality, hospital length of stay, vasopressor-free days in the intensive care unit (ICU) within 28 days, ventilator-free days in the ICU within 28 days, renal replacement-free days in the ICU within 28 days, number of serious adverse reactions and serious adverse events within the first 4 days of admission. DISCUSSION: This trial will test the safety and efficacy of administration of iloprost vs placebo for 72 hours in trauma patients with haemorrhagic shock-induced endotheliopathy. Trial endpoints focus on the potential effect of iloprost to reduce the need for ICU stay secondary to mitigation of organ failure. TRIAL REGISTRATION: SHINE-TRAUMA trial-EudraCT no. 2019-000936-24-Clinicaltrials.gov: NCT03903939 Ethics Committee no. H-19014482.

Failure of short versus long cephalomedullary nail after intertrochanteric fractures.

The aim of study is to examine the frequency of reoperation and difference in failures for short cephalomedullary nail (SN) and long cephalomedullary nail (LN).We included patients with an intertrochanteric fracture treated with Gamma nail (Stryker®). All radiographs were reviewed, TAD and diastasis were measured, and type of failure registered.216 patients were included, 95 short nails and 121 long nails. We found 12 reoperations, 5 in the SN group and 7 in the LN group. Most common failure was cut out. Our study showed no difference in frequency of reoperations or type of failures.

Short versus long intramedullary nails for treatment of intertrochanteric femur fractures (AO 31-A1 and AO 31-A2): a systematic review.

OBJECTIVES: Intramedullary nails are used increasingly in the surgical treatment of intertrochanteric femur fractures (IFFs). However, controversy has developed regarding the length of the nail itself. The purpose of this study is to investigate differences in reoperation rate, as well as operating time, length of hospital stay and 1-year mortality between short and long intramedullary nails in IFF-type AO 31-A1 and AO 31-A2. DATA SOURCES: A search was conducted using PUBMED, Embase and Cochrane Central (January 1, 2000-August 1, 2018). Articles written in English, German or Scandinavian language were included. STUDY SELECTION: Studies with patients > 18 years having an IFF comparing short nail with long nail and a least one of the clinical outcomes on interest (reoperation rate, operating time, length of hospital stay, 1-year mortality) were included. DATA EXTRACTION: A total of 2680 studies were identified and screened according to PRISMA guidelines. Cochrane risk of bias tool for RCTs and non-randomized studies was used to assess the risk of bias. DATA SYNTHESIS: Odds ratio and 95% confidence interval were calculated. CONCLUSIONS: No difference in complication rate leading to reoperation was found in the individual studies or in the meta-analysis [OR 0.89 (0.49; 1.16)]. There is no difference in the length of hospital stay between the two nail cohorts; a shorter operating time inserting a short nail compared to inserting a long nail was found (p < 0.0001). In the meta-analysis, we found no difference in 1-year mortality [OR 1.20 (0.80; 1.79)].