The effect of a single early high-dose vitamin D supplement on fracture union in patients with hypovitaminosis D: a prospective randomised trial.

AIMS: To evaluate the effect of a single early high-dose vitamin D supplement on fracture union in patients with hypovitaminosis D and a long bone fracture. PATIENTS AND METHODS: Between July 2011 and August 2013, 113 adults with a long bone fracture were enrolled in a prospective randomised double-blind placebo-controlled trial. Their serum vitamin D levels were measured and a total of 100 patients were found to be vitamin D deficient (< 20 ng/ml) or insufficient (< 30 ng/mL). These were then randomised to receive a single dose of vitamin D3 orally (100 000 IU) within two weeks of injury (treatment group, n = 50) or a placebo (control group, n = 50). We recorded patient demographics, fracture location and treatment, vitamin D level, time to fracture union and complications, including vitamin D toxicity. Outcomes included union, nonunion or complication requiring an early, unplanned secondary procedure. Patients without an outcome at 15 months and no scheduled follow-up were considered lost to follow-up. The t-test and cross tabulations verified the adequacy of randomisation. An intention-to-treat analysis was carried out. RESULTS: In all, 100 (89%) patients had hypovitaminosis D. Both treatment and control groups had similar demographics and injury characteristics. The initial median vitamin D levels were 16 ng/mL (interquartile range 5 to 28) in both groups (p = 0.885). A total of 14 patients were lost to follow-up (seven from each group), two had fixation failure (one in each group) and one control group patient developed an infection. Overall, the nonunion rate was 4% (two per group). No patient showed signs of clinical toxicity from their supplement. CONCLUSIONS: Despite finding a high level of hypovitaminosis D, the rate of union was high and independent of supplementation with vitamin D3. Cite this article: Bone Joint J 2017;99-B:1520-5.

Benefits of pulsatile flow in pediatric cardiopulmonary bypass procedures: from conception to conduction.

This review on the benefits of pulsatile flow includes not only experimental and clinical data, but also attempts to further illuminate the major factors as to why this debate has continued during the past 55 years. Every single component of the cardiopulmonary bypass (CPB) circuitry is equally important for generating adequate quality of pulsatility, not only the pump. Therefore, translational research is a necessity to select the best components for the circuit. Generation of pulsatile flow depends on an energy gradient; precise quantification in terms of hemodynamic energy levels is, therefore, a necessity, not an option. Comparisons between perfusion modes should be done after these basic steps have been taken. We have also included experimental and clinical data for direct comparisons between the perfusion modes. In addition, we included several suggestions for future clinical trials for other interested investigators.

A directed mutagenesis screen in Drosophila melanogaster reveals new mutants that influence hedgehog signaling.

The Hedgehog signaling pathway has been recognized as essential for patterning processes in development of metazoan animal species. The signaling pathway is, however, not entirely understood. To start to address this problem, we set out to isolate new mutations that influence Hedgehog signaling. We performed a mutagenesis screen for mutations that dominantly suppress Hedgehog overexpression phenotypes in the Drosophila melanogaster wing. We isolated four mutations that influence Hedgehog signaling. These were analyzed in the amenable wing system using genetic and molecular techniques. One of these four mutations affects the stability of the Hedgehog expression domain boundary, also known as the organizer in the developing wing. Another mutation affects a possible Hedgehog autoregulation mechanism, which stabilizes the same boundary.

Thoracolumbar spinal fractures--concepts of treatment.

The treatment of thoracolumbar spinal fractures has evolved significantly in the last 50 years. Clear classification systems now allow physicians to predict which fracture patterns will require surgery and which may be adequately treated non-operatively. These indications, as well as a brief overview of thoracolumbar spinal fracture care, are presented.

Closed-wound drainage systems. The Solcotrans Plus versus the Stryker-CBC ConstaVAC.

Ninety-six patients (63 females and 33 males) who underwent total joint arthroplasty or spinal reconstructive surgery were randomized to receive either a Solcotrans Plus or a Stryker-CBC ConstaVAC closed-wound drainage system. A binomial test showed that the Stryker-CBC ConstaVAC system was significantly preferred over the Solcotrans Plus system for ease of use, as reported by nurses. However, Solcotrans Plus was more cost-effective because a larger volume of blood shed by a patient could be reinfused while maintaining the standards of the American Association of Blood Banks. The difference in the occurrence of side effects between the two systems was not statistically significant.

A successful combination: preadmission testing and preoperative education.

With the advent of prospective pricing, hospitals now have a powerful incentive to improve efficiency and reduce expenses. Prospective pricing incentives are encouraging movement of preoperative teaching out of the inpatient setting. At The Center for Hip and Knee Surgery, a 24-bed research-oriented midwestern orthopaedic hospital, we have developed and implemented an alternative approach to preadmission testing and preoperative patient education.

A randomized clinical trial of insulin and glucagon infusion for treatment of alcoholic hepatitis: progress report in 50 patients.

A randomized, double-blind, controlled trial of insulin and glucagon infusion was conducted in 50 patients with acute alcoholic hepatitis. Twenty-five treatment patients received 24 U regular insulin and 2.4 mg glucagon over 12 h daily for 3 wk. Twenty-five control patients received 200 ml dextrose solution in identical bottles over the same time period. Six control and 2 treatment patients died from liver failure during study, and another treatment patient died from hypoglycemia. In the 34 patients with prothrombin times greater than 3 s prolonged, fewer deaths occurred among the insulin- and glucagon-infused patients (p less than 0.10). Clinical features of liver disease on entry into the study were similar in the two groups, and total serum bilirubin and prothrombin time improved more rapidly in the treatment group (p less than 0.05). Insulin and glucagon infusion is a promising treatment of alcoholic hepatitis and merits further study in the most severely ill patients.

Prognostic indicators of hepatic injury following jejunoileal bypass performed for refractory obesity: a prospective study.

To evaluate factors predisposing to liver injury following jejunoileal bypass, 27 patients underwent clinical evaluation and liver biopsy prior to bypass and at 3, 6, 12, 18, and 24 months and yearly thereafter. Nineteen patients developed increased fatty infiltration of the liver, 1 developed cryptogenic cirrhosis, and 7 developed steatonecrosis, central hyaline sclerosis, or cirrhosis indistinguishable from alcoholic liver disease during the period of rapid weight loss. Two of these 7 patients developed clinical liver failure; inactive cirrhosis evolved after parenteral alimentation and reanastomosis in one, and after oral nutritional supplementation in the other. Four of 5 asymptomatic patients resolved to inactive cirrhosis as weight loss diminished. Each of the 7 patients had pericentral fibrosis on pre-bypass liver biopsies, suggesting a previous hepatic injury. These patients were older (p less than 0.02) and, 3 months following bypass, had greater cumulative per cent weight loss (p less than 0.05), higher levels of serum aspartate aminotransferase (p less than 0.005), and greater 45-min bromosulfophthalein retention (p less than 0.02). Histologic evidence of pericentral fibrosis identified patients at risk to develop steatonecrosis and cirrhosis; these lesions occurred in older patients who had greater weight loss following jejunoileal bypass.

Aminopyrine N-demethylation: a prognostic test of liver function in patients with alcoholic liver disease.

To determine whether results of the aminopyrine breath test, an indirect measurement of functional hepatic microsomal mass, can be correlated with mortality and changes in clinical status and liver function, 51 hospitalized patients who had alcoholic hepatitis were studied prospectively for 3 wk. The aminopyrine breath test was performed weekly, and the results were compared with clinical features of liver disease and SGOT, SGPT, bilirubin, albumin, and prothrombin time. Only an aminopyrine breath test of > 1% of administered dose of 14C as 14CO2 correlated with 3-week survival (P = 0.0075). Only an increase of more than 100% in the aminopyrine breath test was associated with clinical improvement (P = 0.0036). For the 21 patients who had histologic confirmation of alcoholic liver disease, the aminopyrine breath test also correlated best with the degree of histologic severity. In this group of patients with alcoholic hepatitis the aminopyrine breath test predicted short-term survival, clinical improvement, and histologic severity more reliably than conventional liver function tests.