The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition.

BACKGROUND: Severe trauma represents a major global public health burden and the management of post-traumatic bleeding continues to challenge healthcare systems around the world. Post-traumatic bleeding and associated traumatic coagulopathy remain leading causes of potentially preventable multiorgan failure and death if not diagnosed and managed in an appropriate and timely manner. This sixth edition of the European guideline on the management of major bleeding and coagulopathy following traumatic injury aims to advise clinicians who care for the bleeding trauma patient during the initial diagnostic and therapeutic phases of patient management. METHODS: The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma included representatives from six European professional societies and convened to assess and update the previous version of this guideline using a structured, evidence-based consensus approach. Structured literature searches covered the period since the last edition of the guideline, but considered evidence cited previously. The format of this edition has been adjusted to reflect the trend towards concise guideline documents that cite only the highest-quality studies and most relevant literature rather than attempting to provide a comprehensive literature review to accompany each recommendation. RESULTS: This guideline comprises 39 clinical practice recommendations that follow an approximate temporal path for management of the bleeding trauma patient, with recommendations grouped behind key decision points. While approximately one-third of patients who have experienced severe trauma arrive in hospital in a coagulopathic state, a systematic diagnostic and therapeutic approach has been shown to reduce the number of preventable deaths attributable to traumatic injury. CONCLUSION: A multidisciplinary approach and adherence to evidence-based guidelines are pillars of best practice in the management of severely injured trauma patients. Further improvement in outcomes will be achieved by optimising and standardising trauma care in line with the available evidence across Europe and beyond.

The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition.

BACKGROUND: Severe traumatic injury continues to present challenges to healthcare systems around the world, and post-traumatic bleeding remains a leading cause of potentially preventable death among injured patients. Now in its fifth edition, this document aims to provide guidance on the management of major bleeding and coagulopathy following traumatic injury and encourages adaptation of the guiding principles described here to individual institutional circumstances and resources. METHODS: The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004, and the current author group included representatives of six relevant European professional societies. The group applied a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were re-examined and revised based on scientific evidence that has emerged since the previous edition and observed shifts in clinical practice. New recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. RESULTS: Advances in our understanding of the pathophysiology of post-traumatic coagulopathy have supported improved management strategies, including evidence that early, individualised goal-directed treatment improves the outcome of severely injured patients. The overall organisation of the current guideline has been designed to reflect the clinical decision-making process along the patient pathway in an approximate temporal sequence. Recommendations are grouped behind the rationale for key decision points, which are patient- or problem-oriented rather than related to specific treatment modalities. While these recommendations provide guidance for the diagnosis and treatment of major bleeding and coagulopathy, emerging evidence supports the author group's belief that the greatest outcome improvement can be achieved through education and the establishment of and adherence to local clinical management algorithms. CONCLUSIONS: A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. If incorporated into local practice, these clinical practice guidelines have the potential to ensure a uniform standard of care across Europe and beyond and better outcomes for the severely bleeding trauma patient.

The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition.

BACKGROUND: Severe trauma continues to represent a global public health issue and mortality and morbidity in trauma patients remains substantial. A number of initiatives have aimed to provide guidance on the management of trauma patients. This document focuses on the management of major bleeding and coagulopathy following trauma and encourages adaptation of the guiding principles to each local situation and implementation within each institution. METHODS: The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004 and included representatives of six relevant European professional societies. The group used a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were reconsidered and revised based on new scientific evidence and observed shifts in clinical practice; new recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. This guideline represents the fourth edition of a document first published in 2007 and updated in 2010 and 2013. RESULTS: The guideline now recommends that patients be transferred directly to an appropriate trauma treatment centre and encourages use of a restricted volume replacement strategy during initial resuscitation. Best-practice use of blood products during further resuscitation continues to evolve and should be guided by a goal-directed strategy. The identification and management of patients pre-treated with anticoagulant agents continues to pose a real challenge, despite accumulating experience and awareness. The present guideline should be viewed as an educational aid to improve and standardise the care of the bleeding trauma patients across Europe and beyond. This document may also serve as a basis for local implementation. Furthermore, local quality and safety management systems need to be established to specifically assess key measures of bleeding control and outcome. CONCLUSIONS: A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. The implementation of locally adapted treatment algorithms should strive to achieve measureable improvements in patient outcome.

ADRA2A is involved in neuro-endocrine regulation of bone resorption.

Adrenergic stimulation is important for osteoclast differentiation and bone resorption. Previous research shows that this happens through ß2-adrenergic receptor (AR), but there are conflicting evidence on presence and role of α2A-AR in bone. The aim of this study was to investigate the presence of α2A-AR and its involvement in neuro-endocrine signalling of bone remodelling in humans. Real-time polymerase chain reaction (PCR) and immunohistochemistry were used to investigate α2A-AR receptor presence and localization in bone cells. Functionality of rs553668 and rs1800544 single nucleotide polymorphism SNPs located in α2A-AR gene was analysed by qPCR expression on bone samples and luciferase reporter assay in human osteosarcoma HOS cells. Using real-time PCR, genetic association study between rs553668 A>G and rs1800544 C>G SNPs and major bone markers was performed on 661 Slovenian patients with osteoporosis. α2A-AR is expressed in osteoblasts and lining cells but not in osteocytes. SNP rs553668 has a significant influence on α2A-AR mRNA level in human bone samples through the stability of mRNA. α2A-AR gene locus associates with important bone remodelling markers (BMD, CTX, Cathepsin K and pOC). The results of this study are providing comprehensive new evidence that α2A-AR is involved in neuro-endocrine signalling of bone turnover and development of osteoporosis. As shown by our results the neurological signalling is mediated through osteoblasts and result in bone resorption. Genetic study showed association of SNPs in α2A-AR gene locus with bone remodelling markers, identifying the individuals with higher risk of development of osteoporosis.

Education and training initiatives for crisis management in the European Union: a web-based analysis of available programs.

INTRODUCTION: Education and training are key elements of disaster management. Despite national and international educational programs in disaster management, there is no standardized curriculum available to guide the European Union (EU) member states. European- based Disaster Training Curriculum (DITAC), a multiple university-based project financially supported by the EU, is charged with developing a holistic and highly-structured curriculum and courses for responders and crisis managers at a strategic and tactical level. The purpose of this study is to qualitatively assess the prevailing preferences and characteristics of disaster management educational and training initiatives (ETIs) at a postgraduate level that currently exist in the EU countries. METHODS: An Internet-based qualitative search was conducted in 2012 to identify and analyze the current training programs in disaster management. The course characteristics were evaluated for curriculum, teaching methods, modality of delivery, target groups, and funding. RESULTS: The literature search identified 140 ETIs, the majority (78%) located in United Kingdom, France, and Germany. Master level degrees were the primary certificates granted to graduates. Face-to-face education was the most common teaching method (84%). Approximately 80% of the training initiatives offered multi- and cross-disciplinary disaster management content. A competency-based approach to curriculum content was present in 61% of the programs. Emergency responders at the tactical level were the main target group. Almost all programs were self-funded. CONCLUSION: Although ETIs currently exist, they are not broadly available in all 27 EU countries. Also, the curricula do not cover all key elements of disaster management in a standardized and competency-based structure. This study has identified the need to develop a standardized competency-based educational and training program for all European countries that will ensure the practice and policies that meet both the standards of care and the broader expectations for professionalization of the disaster and crisis workforce.

Identifying deficiencies in national and foreign medical team responses through expert opinion surveys: implications for education and training.

INTRODUCTION: Unacceptable practices in the delivery of international medical assistance are reported after every major international disaster; this raises concerns about the clinical competence and practice of some foreign medical teams (FMTs). The aim of this study is to explore and analyze the opinions of disaster management experts about potential deficiencies in the art and science of national and FMTs during disasters and the impact these opinions might have on competency-based education and training. METHOD: This qualitative study was performed in 2013. A questionnaire-based evaluation of experts' opinions and experiences in responding to disasters was conducted. The selection of the experts was done using the purposeful sampling method, and the sample size was considered by data saturation. Content analysis was used to explore the implications of the data. RESULTS: This study shows that there is a lack of competency-based training for disaster responders. Developing and performing standardized training courses is influenced by shortcomings in budget, expertise, and standards. There is a lack of both coordination and integration among teams and their activities during disasters. The participants of this study emphasized problems concerning access to relevant resources during disasters. CONCLUSION: The major findings of this study suggest that teams often are not competent during the response phase because of education and training deficiencies. Foreign medical teams and medically related nongovernmental organizations (NGOs) do not always provide expected capabilities and services. Failures in leadership and in coordination among teams are also a problem. All deficiencies need to be applied to competency-based curricula.

Triglyceride metabolism in bone tissue is associated with osteoblast and osteoclast differentiation: a gene expression study.

The role of bone marrow adipocytes in bone tissue is not yet understood. Adipocytes express enzymes for metabolism of free fatty acids and adipokines such as adiponectin, which have been shown to exert different effects on bone cells. Our aim was to find out whether triglyceride (TG) metabolism in bone tissue is associated with osteoblast and osteoclast differentiation by gene expression analysis of lipoprotein lipase (LPL), hormone sensitive lipase (HSL), fatty acid synthase (FASN), adiponectin, RUNX2, RANK, RANKL and OPG. Bone tissue was obtained from patients undergoing hip arthroplasty due to osteoporosis (OP) (50) or osteoarthritis (OA) (48) or from healthy autopsy controls (14). Lower bone mineral density and microstructural parameters were observed in OP compared to OA. The FASN expression did not differ between groups suggesting similar de novo lipogenesis. Lower LPL and HSL in OP suggest lower FFA release and uptake in OP bone tissue. Adiponectin expression was lower in OP than in OA and a trend was seen for controls. These results suggest OP bone has lower TG metabolism than OA and normal bone. In OP bone, lower osteoblastogenesis and higher osteoclast formation were observed and correlation analysis suggests adiponectin, LPL and HSL are associated with higher osteoblastogenesis and lower osteoclastogenesis. This study gives insights into TG metabolism in the human bone microenvironment. We conclude that OP bone tissue exhibits lower osteoblastogenesis, higher osteoclastogenesis and lower TG metabolism compared to OA or healthy controls.

Management of bleeding and coagulopathy following major trauma: an updated European guideline.

INTRODUCTION: Evidence-based recommendations are needed to guide the acute management of the bleeding trauma patient. When these recommendations are implemented patient outcomes may be improved. METHODS: The multidisciplinary Task Force for Advanced Bleeding Care in Trauma was formed in 2005 with the aim of developing a guideline for the management of bleeding following severe injury. This document represents an updated version of the guideline published by the group in 2007 and updated in 2010. Recommendations were formulated using a nominal group process, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) hierarchy of evidence and based on a systematic review of published literature. RESULTS: Key changes encompassed in this version of the guideline include new recommendations on the appropriate use of vasopressors and inotropic agents, and reflect an awareness of the growing number of patients in the population at large treated with antiplatelet agents and/or oral anticoagulants. The current guideline also includes recommendations and a discussion of thromboprophylactic strategies for all patients following traumatic injury. The most significant addition is a new section that discusses the need for every institution to develop, implement and adhere to an evidence-based clinical protocol to manage traumatically injured patients. The remaining recommendations have been re-evaluated and graded based on literature published since the last edition of the guideline. Consideration was also given to changes in clinical practice that have taken place during this time period as a result of both new evidence and changes in the general availability of relevant agents and technologies. CONCLUSIONS: A comprehensive, multidisciplinary approach to trauma care and mechanisms with which to ensure that established protocols are consistently implemented will ensure a uniform and high standard of care across Europe and beyond.

The STOP the Bleeding Campaign.

According to the World Health Organization, traumatic injuries worldwide are responsible for over 5 million deaths annually. Post-traumatic bleeding caused by traumatic injury-associated coagulopathy is the leading cause of potentially preventable death among trauma patients. Despite these facts, awareness of this problem is insufficient and treatment options are often unclear. The STOP the Bleeding Campaign therefore aims to increase awareness of the phenomenon of post-traumatic coagulopathy and its appropriate management by publishing European guidelines for the management of the bleeding trauma patient, by promoting and monitoring the implementation of these guidelines and by preparing promotional and educational material, organising activities and developing health quality management tools. The campaign aims to reduce the number of patients who die within 24 hours after arrival in the hospital due to exsanguination by a minimum of 20% within the next 5 years.

Arterial angioembolisation versus pre-peritoneal pelvic packing in haemodynamically unstable patients with complex pelvic fractures: a meta-analysis.

INTRODUCTION: Angioembolisation (AE) and/or pre-peritoneal pelvic packing (PPP) may be necessary for patients with complex pelvic fractures who are haemodynamically unstable. However, it remains unclear whether AE or PPP should be performed as an initial intervention and ongoing debates exist. This meta-analysis aimed to compare AE versus PPP in haemodynamically unstable patients with acute pelvic fractures. The primary outcomes of interest were to compare in-hospital mortality rate and number of blood units transfused. Secondary outcomes included evaluating differences in the time from diagnosis to treatment, as well as the length of stay in the intensive care unit (ICU) and hospital. METHODS: All clinically relevant studies comparing AE versus PPP in patients with complex pelvic fractures and haemodynamic instability were accessed. The 2020 PRISMA guidelines were followed. In September 2023, the following databases were accessed: PubMed, Web of Science, Google Scholar and Embase, without constraint. RESULTS: Data from 320 patients were collected (AE: 174; PPP: 146). The mean age on admission was 47.4 ± 7.2 years. The mean Injury Severity Score (ISS) on admission was 43.5 + 5.4 points. Baseline comparability was observed in ISS (P = 0.5, Table 3) and mean age (P = 0.7, Table 3). No difference was reported in mortality rate (P = 0.2) or rate of blood units transfused (P = 0.3). AE had a longer mean time to the procedure of 44.6 min compared to PPP (P = 0.04). The mean length of ICU and hospital stay were similar in both groups. CONCLUSION: Despite the longer mean time from admission to the procedure, no significant differences were found between AE and PPP in terms of in-hospital mortality, blood units transfused, or length of ICU, and hospital stay. These findings should be interpreted considering the limitations of the present study. High-quality comparative research is strongly warranted. LEVEL OF EVIDENCE: Level IV, meta-analysis.

The relationship between osteoclastogenic and anti-osteoclastogenic pro-inflammatory cytokines differs in human osteoporotic and osteoarthritic bone tissues.

BACKGROUND: Pro-inflammatory cytokines possess osteoclastogenic or anti-osteoclastogenic activities. They influence osteoclasts directly or via the receptor activator of nuclear factor κB (RANK), RANK ligand (RANKL) and osteoprotegerin (OPG) system. Recent evidence suggests that inflammation may play a role in osteoporosis (OP) and osteoarthritis (OA). We aimed therefore to determine whether there is a difference between both groups: first, in the expression of the osteoclastogenic and anti-osteoclastogenic cytokines, second, in correlation of these cytokines with bone mineral density (BMD) and levels of bone turnover markers (BTM) and third, in correlation between the expression of these cytokines and osteoclast specific genes and RANK/RANKL/OPG genes. METHODS: Human bone samples from 54 age and sex matched patients with OP or OA were collected during hip arthroplasty surgery. The expression of 25 genes encoding pro-inflammatory cytokines, their receptors, osteoclast specific genes and RANK/RANKL/OPG genes was measured using quantitative real-time PCR. Total hip, femoral neck and lumbar spine BMD and BTM in blood samples were measured. The comparison between OP and OA was assessed using Student's t-test or Mann-Whitney U test and correlations between gene expression, BMD and BTM were determined using nonparametric correlation. RESULTS: The results demonstrated a higher expression of interleukin (IL)-6 and IL-1α in OP, and interferon (IFN)-γ in OA (p < 0.0005). Negative correlations of total hip BMD with tumor necrosis factor-α (TNF-α) in OA and with RANKL/RANK in OP were found (p < 0.05). Significant correlations with BTM were shown for IL-1α and IFN-γ in OP (rho = 0.608 and -0.634) and for TNF-α, IL-6 and transforming growth factor-ß1 (TGF-ß1) in OA (rho = 0.591, -0.521 and 0.636). Results showed OP specific negative correlations (IFN-γ with ITGB3, IFN-ß1 with CTSK, tartrate resistant acid phosphatase (TRAP), CALCR, RANK, RANKL, IL-1α with CTSK, OPG, IL-17A with CALCR) and positive (TGF-ß1 with CTSK, TRAP, RANK), and OA specific negative (IL-1α with osteoclast associated immunoglobulin-like receptor (OSCAR), TNF-α with RANK, RANKL, OPG) and positive (IL-6 with RANK, RANKL, OPG) correlations. CONCLUSIONS: Our results demonstrate that the relationship between osteoclastogenic and anti-osteoclastogenic pro-inflammatory cytokines differs in human OP and OA bone and could present an important factor for characteristics of OP and OA bone phenotypes.

Interleukin-1α gene variants influence bone mineral density and the risk of osteoporotic hip fractures in elderly Slovenian people.

BACKGROUND: Osteoporosis is a skeletal disorder, characterized by low bone mass and microarchitectural deterioration of bone tissue, leading to increased risk of fracture. Recently, the role of age-related pro-inflammatory cytokines, such as interleukin (IL)-1α, in stimulating bone resorption has been suggested. As osteoporosis has a strong genetic background, the aim of our study was to evaluate the association of two IL-1α gene single nucleotide polymorphisms (SNPs) rs2071375 (+12534G>A) and rs17651 (+4845G>T) with osteoporotic phenotypes as well as to find the association with IL-1α gene expression in human bone tissue. METHODS: Genotyping was performed in 671 Slovenian participants, 125 elderly men, 490 post- and 56 premenopausal women. Bone mineral density (BMD) at the lumbar spine, femoral neck and total hip were measured. Biochemical markers of bone turnover were measured in women. RESULTS: Significant association of GG/TA haplotype with higher femoral neck and total hip BMD in elderly men and women was shown (p=0.009 and 0.030, respectively). In men, the association of the GG/GG haplotype with higher femoral neck BMD was of limited statistical significance (p=0.050). In women, significant association of studied genetic variants with serum C-terminal crosslinking telopeptides of type I collagen and bone alkaline phosphatase were found (p=0.033 and 0.029, respectively). No influence on IL-1α expression was found. Finally, significantly lower odds ratio for hip fracture associated with the presence of TA haplotype was found (p=0.026). CONCLUSIONS: Our results of the association of IL-1α gene single nucleotide polymorphisms (SNPs) rs2071375 (+12534G>A) and rs17651 (+4845G>T) with osteoporotic features indicate its role in pathogenesis of osteoporosis. However, these findings need further functional and clinical confirmation.

Measurement of spinal sagittal curvatures using the laser triangulation method.

The purpose of the first part of the study was to establish the variability of repeated measurements in different measuring conditions. In the second part, we performed in a large number of patients, a measurement of thoracic kyphosis and lumbar lordosis and compared them to age, gender, and level of nourishment. In the first part, measurements were performed on a plastic model of the back of a patient with a rigid and a normal spine. In the second part, 250 patients participated in the study (126 men and 124 women). For measuring spinal curvatures we used an apparatus for laser triangulation constructed at the Faculty of Mechanical Engineering, University of Ljubljana. A comparison of 30 repeated measurements was shown as the average value +/- 2 SD which included 95% of the results. Thirty repeated readings of one 3D measurement: thoracic kyphosis 41.2 degrees +/- 0.6 degrees, lumbar lordosis 4.4 degrees +/- 1.2 degrees; 30 measurements on a plastic model: thoracic kyphosis 36.8 degrees +/- 1.2 degrees, lumbar lordosis 30.9 degrees +/- 2.0 degrees; 30 measurements on a patient with a rigid spine: thoracic kyphosis 41.5 degrees +/- 2.4 degrees, lumbar lordosis 4.0 degrees +/- 1.8 degrees; 30 measurements on a patient with a normal spine: thoracic kyphosis 48.8 degrees +/- 7.4 degrees, lumbar lordosis 21.1 degrees +/- 4.4 degrees. The average size of thoracic kyphosis in 250 patients was 46.8 degrees (SD 10.1 degrees) and lumbar lordosis 31.7 degrees (SD 12.5 degrees). The angle size was statistically significantly correlated to gender (increased thoracic kyphosis and lumbar lordosis in women) and body mass index (increased thoracic kyphosis and lumbar lordosis in more nourished patients). Age was not significantly correlated to the observed angles. During measurements of the spinal angles it was important to pay attention to relaxation and the patient's position as well as to perform more measurements providing the average value. The age and the level of nourishment influence the size of the sagittal spinal angles. In the observed sample the effect of age was not confirmed.

Standards of fracture care in polytrauma: results of a Europe-wide survey by the ESTES polytrauma section.

INTRODUCTION: Fixation of major fractures plays a pivotal role in the surgical treatment of polytrauma patients. In addition to ongoing discussions regarding the optimal timing in level I trauma centers, it appears that the respective trauma systems impact the implementation of both, damage control and safe definitive surgery strategies. This study aimed to assess current standards of polytrauma treatment in a Europe-wide survey. METHODS: A survey, developed by members of the polytrauma section of ESTES, was sent online via SurveyMonkey®, between July and November 2020, to 450 members of ESTES (European Society of Trauma and Emergency Surgery). Participation was voluntary and anonymity was granted. The questionnaire consisted of demographic data and included questions about the definition of "polytrauma" and the local standards for the timing of fracture fixation. RESULTS: In total, questionnaires of 87 participants (19.3% response rate) were included. The majority of participants were senior consultants (50.57%). The mean work experience was 19 years, and on average, 17 multiple-injured patients were treated monthly. Most of the participants stated that a polytrauma patient is defined by ISS ≥ 16 (44.16%), followed by the "Berlin Definition" (25.97%). Systolic blood pressure < 90 mmHg, tachycardia or vasopressor administration (86.84%), pH deviation, base excess shift (48.68%), and lactate > 4 mmol (40.79%) or coagulopathy defined by ROTEM (40.79%) were the three most often stated indicators for shock. Local guidelines (33.77%) and the S-3 Guideline by the DGU® (23.38%) were mostly stated as a reference for the treatment of polytrauma patients. Normal coagulation (79.69%), missing administration of vasopressors (62.50%), and missing clinical signs of "SIRS" (67.19%) were stated as criteria for safe definite secondary surgery. CONCLUSION: Different definitions of polytrauma are used in the clinical setting. Indication for and the extent of secondary (definitive) surgery are mainly dependent on the polytrauma patient`s physiology. The «Window of Opportunity¼ plays a less important role in decision making.

-1227C>T polymorphism in the pleiotrophin gene promoter influences bone mineral density in postmenopausal women.

Our gene expression microarray data of primary cultures of osteoblasts revealed that the expression of the pleiotrophin (PTN) gene is decreased in osteoporosis. PTN is involved in osteoblasts' proliferation and differentiation, response to mechanical stimuli and cross-talk with Wnt signaling. On the basis of these findings, we studied the PTN gene as a candidate gene for genetic susceptibility to osteoporosis. The aim of the study was to evaluate the association of two PTN gene promoter polymorphisms with osteoporotic phenotype in postmenopausal women. 530 postmenopausal women, 480 without and 50 with hip fracture, were genotyped for the presence of PTN gene promoter polymorphisms -1734C>T (rs161335) and -1227C>T (rs321198). Three common haplotypes, CC (14.2%), CT (42.8%) and TC (42.9%), were inferred. Bone mineral densities (BMDs) at lumbar spine and (contralateral) hip were measured. In non-osteoporotic postmenopausal women without hip fracture, the association of -1227C>T and CT haplotype with lumbar spine BMD was shown (p=0.014 and 0.014). No other significant association of the studied genotypes and haplotypes in the PTN gene promoter with BMDs was found. Comparing age-matched postmenopausal women with and without hip fractures, no differences in frequency distributions of the studied genotypes and haplotypes was shown. For the first time we have shown that, in postmenopausal women, the PTN gene promoter polymorphism -1227C>T and CT haplotype could contribute to the genetic background of osteoporosis, but these findings need further functional and clinical confirmation.

ESTES recommendations on proximal humerus fractures in the elderly.

PURPOSE: The section for the skeletal trauma and sport's injuries of the European Society for Trauma and Emergency Surgery (ESTES) appointed a task force group to reach a consensus among European countries on proximal humeral fractures. MATERIAL/METHODS: The task force group organized several consensus meetings until a paper with final recommendations was confirmed during the ESTES Executive Board meeting in Berlin on 25 October 2018. CONCLUSION: The Recommendations compare conservative and four possible operative treatment options (ORIF, nailing, hemi- and total reverse arthroplasty) and enable the smallest common denominator for the surgical treatment among ESTES members.

Indications and interventions of damage control orthopedic surgeries: an expert opinion survey.

OBJECTIVES: The objectives of this study were to gather an expert opinion survey and to evaluate the suitability of summarized indications and interventions for DCO. BACKGROUND: The indications to perform temporary surgery in musculoskeletal injuries may vary during the hospitalization and have not been defined. We performed a literature review and an expert opinion survey about the indications for damage control orthopaedics (DCO). METHODS: Part I: A literature review was performed on the basis of the PubMed library search. Publications were screened for damage control interventions in the following anatomic regions: "Spine", "Pelvis", "Extremities" and "Soft Tissues". A standardized questionnaire was developed including a list of damage control interventions and associated indications. Part II: Development of the expert opinion survey: experienced trauma and orthopaedic surgeons participated in the consensus process. RESULTS: Part I: A total of 646 references were obtained on the basis of the MeSH terms search. 74 manuscripts were included. Part II: Twelve experts in the field of polytrauma management met at three consensus meetings. We identified 12 interventions and 79 indications for DCO. In spinal trauma, percutaneous interventions were determined beneficial. Traction was considered harmful. For isolated injuries, a new terminology should be used: "MusculoSkeletal Temporary Surgery". CONCLUSION: This review demonstrates a detailed description of the management consensus for abbreviated musculoskeletal surgeries. It was consented that early fixation is crucial for all major fractures, and certain indications for DCO were dropped. Authors propose a distinct terminology to separate local (MuST surgery) versus systemic (polytrauma: DCO) scenarios.

Management of bleeding following major trauma: an updated European guideline.

INTRODUCTION: Evidence-based recommendations are needed to guide the acute management of the bleeding trauma patient, which when implemented may improve patient outcomes. METHODS: The multidisciplinary Task Force for Advanced Bleeding Care in Trauma was formed in 2005 with the aim of developing a guideline for the management of bleeding following severe injury. This document presents an updated version of the guideline published by the group in 2007. Recommendations were formulated using a nominal group process, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) hierarchy of evidence and based on a systematic review of published literature. RESULTS: Key changes encompassed in this version of the guideline include new recommendations on coagulation support and monitoring and the appropriate use of local haemostatic measures, tourniquets, calcium and desmopressin in the bleeding trauma patient. The remaining recommendations have been reevaluated and graded based on literature published since the last edition of the guideline. Consideration was also given to changes in clinical practice that have taken place during this time period as a result of both new evidence and changes in the general availability of relevant agents and technologies. CONCLUSIONS: This guideline provides an evidence-based multidisciplinary approach to the management of critically injured bleeding trauma patients.

Mobile wireless monitoring system for prehospital emergency care.

BACKGROUND: Latest achievement technologies allow engineers to develop medical systems that medical doctors in the health care system could not imagine years ago. The development of signal theory, intelligent systems, biophysics and extensive collaboration between science and technology researchers and medical professionals, open up the potential for preventive, real-time monitoring of patients. With the recent developments of new methods in medicine, it is also possible to predict the trends of the disease development as well the systemic support in diagnose setting. Within the framework of the needs to track the patient health parameters in the hospital environment or in the case of road accidents, the researchers had to integrate the knowledge and experiences of medical specialists in emergency medicine who have participated in the development of a mobile wireless monitoring system designed for real-time monitoring of victim vital parameters. Emergency medicine responders are first point of care for trauma victim providing prehospital care, including triage and treatment at the scene of incident and transport from the scene to the hospital. Continuous monitoring of life functions allows immediate detection of a deterioration in health status and helps out in carrying out principle of continuous e-triage. In this study, a mobile wireless monitoring system for measuring and recording the vital parameters of the patient was presented and evaluated. Based on the measured values, the system is able to make triage and assign treatment priority for the patient. The system also provides the opportunity to take a picture of the injury, mark the injured body parts, calculate Glasgow Coma Score, or insert/record the medication given to the patient. Evaluation of the system was made using the Technology Acceptance Model (TAM). In particular we measured: perceived usefulness, perceived ease of use, attitude, intention to use, patient status and environmental status. METHODS: A functional prototype of a developed wireless sensor-based system was installed at the emergency medical (EM) department, and presented to the participants of this study. Thirty participants, paramedics and doctors from the emergency department participated in the study. Two scenarios common for the prehospital emergency routines were considered for the evaluation. Participants were asked to answer the questions referred to these scenarios by rating each of the items on a 5-point Likert scale. RESULTS: Path coefficients between each measured variable were calculated. All coefficients were positive, but the statistically significant were only the following: patient status and perceive usefulness (ß = 0.284, t = 2.097), environment (both urban a nd rural) and perceive usefulness (ß = 0.247, t = 2.570; ß = 0.329, t = 2.083, respectively), and perceive usefulness and behavioral intention (ß = 0.621 t = 7.269). The variance of intention is 47.9%. CONCLUSIONS: The study results show that the proposed system is well accepted by the EM personnel and can be used as a complementary system in EM department for continuous monitoring of patients' vital signs.

Analysis of association of LRP5, LRP6, SOST, DKK1, and CTNNB1 genes with bone mineral density in a Slovenian population.

The Wnt pathway has a bifunctional role in bone mass regulation, influencing osteoblasts and osteoclasts. The Wnt pathway genes are therefore candidate genes for susceptibility to osteoporosis. In our study, we focused on the effects of polymorphisms in selected Wnt pathway genes: low-density lipoprotein receptor-related proteins 5 and 6 (LRP5 and LRP6), Dickkopf1 (DKK1), sclerostin (SOST), and beta-catenin (CTNNB1). We genotyped 652 subjects for the following polymorphisms: A1330V in LRP5; I1062V in LRP6; E232K in DKK1; D32Y, G34V, and N287S in CTNNB1; and -1397_-1396insGGA in SOST. Bone mineral density (BMD) was also measured. The allele frequencies were as follows: for A1330V C:T = 87%:13%, for I1062V C:T = 20%:80%, and for -1397_-1396insGGA-:GGA = 64%:36%. The studied nucleotide changes in the DKK1 and CTNNB1 genes were shown not to be polymorphic. In a Slovenian population, no association was shown between lumbar spine and femoral neck BMD in A1330V (P = 0.151 and 0.243) and in I1062V (P = 0.209 and 0.405). We observed a difference between SOST genotypes, corresponding to an allele dose effect, which was borderline significant for lumbar spine and femoral neck BMD (P = 0.047 and 0.085); but this did not survive the adjustment for multiple testing. These results indicate that a larger sample size would be necessary to detect these subtle effects. Our results suggest that A1330V in LRP5, I1062V in LRP6, and -1397_-1396insGGA in SOST are not associated with BMD in the Slovenian population.