Culprit lesion plaque characterization and thrombus grading by high-definition intravascular ultrasound in patients with ST-segment elevation myocardial infarction.

BACKGROUND: Dedicated prospective studies investigating high-definition intravascular ultrasound (HD-IVUS)-guided primary percutaneous coronary intervention (PCI) are lacking. The aim of this study was to qualify and quantify culprit lesion plaque characteristics and thrombus using HD-IVUS in patients presenting with ST-segment elevation myocardial infarction (STEMI). METHODS: The SPECTRUM study is a prospective, single-center, observational cohort study investigating the impact of HD-IVUS-guided primary PCI in 200 STEMI patients (NCT05007535). The first 100 study patients with a de novo culprit lesion and a per-protocol mandated preintervention pullback directly after vessel wiring were subject to a predefined imaging analysis. Culprit lesion plaque characteristics and different thrombus types were assessed. An IVUS-derived thrombus score, including a 1-point adjudication for a long total thrombus length, long occlusive thrombus length, and large maximum thrombus angle, was developed to differentiate between low (0-1 points) and high (2-3 points) thrombus burden. Optimal cut-off values were obtained using receiver operating characteristic curves. RESULTS: The mean age was 63.5 (±12.1) years and 69 (69.0%) patients were male. The median culprit lesion length was 33.5 (22.8-38.9) mm. Plaque rupture and convex calcium were appreciated in 48 (48.0%) and 10 (10.0%) patients, respectively. Thrombus was observed in 91 (91.0%) patients (acute thrombus 3.3%; subacute thrombus 100.0%; organized thrombus 22.0%). High IVUS-derived thrombus burden was present in 37/91 (40.7%) patients and was associated with higher rates of impaired final thrombolysis in myocardial infarction flow (grade 0-2) (27.0% vs. 1.9%, p < 0.001). CONCLUSIONS: HD-IVUS in patients presenting with STEMI allows detailed culprit lesion plaque characterization and thrombus grading that may guide tailored PCI.

Weight-Bearing Computed Tomography of the Foot and Ankle in the Pediatric Population.

BACKGROUND: Newer cone-beam computed tomography (CT) technology has grown in popularity for evaluation of foot and ankle pathology in the weight-bearing (WB) position. Many studies have demonstrated its benefits within the adult population, but there is a paucity of its use within the pediatric literature. The purpose of this study was to describe the indications and clinical findings of WBCT within a pediatric population. METHODS: A retrospective cohort of 68 patients (86 extremities) who underwent WBCT for a variety of conditions were compared with 48 patients (59 extremities) who underwent traditional supine nonweight-bearing (NWB) CTs. Clinical indications, demographic data, radiation doses, and cost were obtained from the medical record. WBCTs were obtained in a private outpatient orthopaedic clinic, and the conventional NWBCTs were obtained within a hospital-based system. RESULTS: The most common indications for obtaining a WBCT and NWBCT in our study were fracture, tarsal coalition, and Lisfranc injury. The average WBCT radiation dose was 0.63 mGy for patients <100 lbs and 1.1 mGy for patients >100 lbs undergoing WBCT. For NWBCTs, the average radiation dose was 7.92 mGy for patients <100 lbs and 10.37 mGy for patients greater than 100 lbs. There was a significant reduction in radiation dose for all patients who underwent WBCT (P<0.0001 vs. 0.002). The average reimbursement for NWBCTs was $505 for unilateral studies and $1451 for bilateral studies. The average reimbursement for the WBCTs was $345 for unilateral studies and $635 for bilateral studies. CONCLUSIONS: WBCT offers a new modality for studying complex foot and ankle pathoanatomy in the pediatric population at a reduced radiation exposure and reduced cost. LEVEL OF EVIDENCE: Level III-a retrospective comparative study.

Donor site morbidity of calcaneal, distal tibial, and proximal tibial cancellous bone autografts in foot and ankle surgery. A systematic review and meta-analysis of 2296 bone grafts.

PURPOSE: This study aims to report on the safety and donor site morbidity of the distal lower extremity (calcaneal, proximal, and distal tibial) cancellous bone autografts. We summarized the findings in a comprehensive infographic illustration. We are unaware of any similar meta-analyses to date. METHODS: Following the PRISMA guidelines, two independent investigators searched MEDLINE (PubMed), EMBASE, SCOPUS, Google Scholar, and Cochrane databases in December 2020 using the following keywords and their synonyms: ("bone graft", "donor site morbidity", "calcaneal graft", "proximal tibia graft", and "distal tibia graft"). Besides, the reference lists from previous review articles were searched manually for eligible studies. The primary outcomes of interest were (1) chronic pain, (2) fracture, and (3) infection, whereas the secondary outcomes were (1) neurological complications, (2) sensory disturbance and hypertrophic scars, (3) other complications such as shoe-wear difficulties and gait disturbance. Inclusion criteria were: studies on complications and adverse events of lower extremity bone autografts (calcaneal, proximal tibial, and distal tibial bone autografts) reporting at least one of the desired outcomes. Studies not reporting any of the outcomes of interest or if the full text is not available in English were excluded. Studies reporting on bone marrow aspirate or autografts for non-orthopedic indications were also excluded. RESULTS: After the removal of duplicates, a total of 5981 studies were identified. After screening those records, 85 studies remained for full-text assessment. Out of those, 15 studies qualified for the meta-analysis with a total of 2296 bone grafts. Out of those grafts, 1557(67.8%) were calcaneal grafts, 625 (27.2%) were proximal tibial grafts, and 114 (5%) were distal tibial grafts. In calcaneal bone grafts, there were 28 cases of chronic pain [1.97%, CI:1.10-2.50%, I2 = 66%], 5 fractures [0.32%, CI: 0.10-0.60%,I2 = 0%], 20 sural neuritis [1.28%, CI:0.70-1.80%, I2 = 0%), and no wound infections. In proximal tibial grafts there were 13 cases of chronic pain [2.08%, CI: 1.01-3.2%, I2 = 34.5%], 1 fracture [0.16%, CI:0.10-0.50%, I2 = 0%], and 3 superficial wound infections [0.48%, CI: 0.10-1.01, I2 = 0%]. In the distal tibial grafts there were no cases of chronic pain or wound infections, 1 fracture [0.90%, CI: 0.80-2.6%, I2 = 0%], and 5 saphenous neuritis [4.5%, CI: 0.70-8.40%, I2 = 65%]. CONCLUSION: Calcaneal, distal tibial, and proximal tibial bone autografts are safe with a low rate of overall and major complications. We report an overall complication rate of 6.8%, which is less than half of that previously reported for iliac crest grafts. The authors recommend using distal lower extremity grafts for foot and ankle primary surgeries instead of iliac crest grafts when indicated. Clinical trials with a large sample size are required.

Locked intramedullary nailing provides superior functional outcomes and lower complication rates than plate fixation of distal fibula fractures. A systematic review and meta-analysis of comparative studies.

PURPOSE: This study aims to provide an updated systematic review and meta-analysis of comparative studies on the outcomes and complications of locked IMNs in comparison to ORIF using plates and screws, while avoiding limitations of similar published reviews. METHODS: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, two independent team members electronically searched MEDLINE (PubMed), EMBASE, Google Scholar, SCOPUS, and Cochrane databases throughout May 2021 using the following keywords with their synonyms: "Ankle fracture fixation" AND "Open reduction and internal fixation", "locked intramedullary nail", or "complications". The primary outcomes were (1) functional outcomes, (2) complications, and (3) reoperation, while the secondary outcomes were: (1) union rate, and (2) cost. INCLUSION CRITERIA: comparative studies on outcomes and complications of plate open reduction and internal fixation (ORIF) vs. locked intramedullary nailing (IMN) of ankle fractures reporting at least one of the following parameters: functional outcomes, complications (infection, dehiscence, reoperation etc.), union, and cost. Studies reporting on non-locked intramedullary fibular nails were also excluded. RESULTS: After the removal of duplicates, a total of 1461 studies were identified. After screening those records, 63 studies remained for full-text assessment. Out of those, four comparative studies with a total of 262 ankle fractures met the inclusion criteria for this meta-analysis. The mean 12 months postoperative Olerud and Molander Ankle Scores (OMAS) were reported by two studies, with a statistically significant difference in favor of IMNs (MD= 6.72, CI: 3.77-9.67, p<0.001, I2= 94%). In the ORIF group, the overall complication rate was 39/134 (29.1%) vs. 10/128 (7.8%) in the IMN group, with a statistically significant difference in favor of the IMN group (RR=3.23, CI:1.71-6.11, p<0.001, I2=34%). In the ORIF group, the overall infection rate was 11/134 (8.2%), while there were no infections in the IMN group, with a statistically significant difference in favor of the IMN group (RR=8.05, CI:1.51-42.82, p=0.01, I2=0%). In the ORIF group, the overall reoperation rate was 10/134 (7.5%) while the overall reoperation rate was 6/128 (4.7%) in the IMN group, with no statistically significant difference between groups (RR=1.49, CI: 0.60-3.70, p = 0.39, I2=0%). CONCLUSION: Locked intramedullary nail fixation of distal fibula fractures could provide superior functional outcomes and lower complication rates in comparison to open reduction and plate fixation. Despite the high incidence of ankle fractures, the number of high-quality comparative studies remains limited in literature, especially on newer locked fibular nails, and large multicentric clinical trials are required before recommending locked IMNs as the new standard of care in distal fibula fractures.

Adverse events related to total ankle replacement devices: an analysis of reports to the United States Food and Drug Administration.

BACKGROUND: The published outcomes of total ankle replacement (TAR) implants came from limited institutions creating observational bias. For broader perspective, we queried the Food and Drug Administration's (FDA) Manufacturer and User Facility Device Experience (MAUDE) voluntary database to explore complications reported outside published literature. METHODS: The database was reviewed retrospectively between November 2011 and April 2019 using two product codes assigned to six TAR devices. RESULTS: Among 648 relevant reports available in the database, common complications were aseptic loosening (19.3%), infection (18.2%), and alignment/mechanical issues (16.5%). Others included instrument/instrumentation complications, impingement, polyethylene problems, fractures, avascular necrosis of talus (AVN), and packaging issues. CONCLUSION: MAUDE database revealed various patterns of device-related malfunctions that have been under-reported in published data. Despite inconsistency in the available reports, it provided opportunities for improvements in quality control, device design, and ultimately patient safety. Database would be further strengthened by more robust reporting mechanism or mandatory reporting of device-related complications.

Return to sport following navicular stress fracture: a systematic review and meta-analysis of three hundred and fifteen fractures.

PURPOSE: This meta-analysis aims to provide updated evidence on the success rate, return to play (RTP) rate, time to RTP, and complications of operatively and conservatively managed navicular stress fractures (NSFs) as well as delays in diagnosis while avoiding limitations of previous similar studies. METHODS: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, two independent team members electronically searched MEDLINE (PubMed), EMBASE, Google Scholar, SCOPUS, and Cochrane databases throughout February 2021 using the following keywords with their synonyms: "Navicular stress fracture," "return to play," and "athletes." The primary outcomes were (1) management success rate, (2) RTP rate, and (3) time to RTP. The secondary outcomes were (1) non-union, (2) time to diagnosis, (3) refracture, and (4) other complications. Inclusion criteria were clinical studies on NSFs reporting at least one of the desirable outcomes. Studies not reporting any of the outcomes of interest or the full text was not available in English, German, French, or Arabic were excluded. Case reports, case series with less than ten cases, and studies reporting exclusively on navicular non-union management were also excluded. The Newcastle-Ottawa scale was used for quality assessment while Review Manager (RevMan) Version 5.4 was used for the risk of bias assessment. Data were presented by type of treatment (surgical or conservative). If enough studies were present that were clinically and statistically homogeneous and data on them adequately reported, a meta-analysis was performed using a fixed-effects model. In case of statistical heterogeneity, a random-effects model was used. If meta-analysis was not possible, results were reported in a descriptive fashion. The need to explore for statistical heterogeneity was determined by an I2 greater than 40%. RESULTS: Eleven studies met the inclusion criteria with a total of 315 NSF. Out of those, 307 (97.46%) NSFs were in athletes. One hundred eight (34.29%) NSFs were managed operatively, while 207 (65.71%) NSFs were managed conservatively. Successful outcomes were reported in 104/108 (96.30%) NSF treated operatively with a mean success rate of 97.9% (CI: 95.4-100%, I2 = 0%). Successful outcomes were reported in 149/207 (71.98%) NSF treated conservatively, with a mean success rate of 78.1% (CI: 66.6-89.6%, I2 = 84.93%). Successful outcome differences were found to be significant in favor of operative management (OR = 5.52, CI: 1.74-17.48, p = 0.004, I2 = 4.6%). RTP was noted in 97/98 (98.98%) NSF treated operatively and in 152/207 (73.43%) NSF treated conservatively, with no significant difference between operative and conservative management (OR = 2.789, CI: 0.80-9.67, p = 0.142, I2 = 0%). The pooled mean time to RTP in NSF treated operatively was 4.17 months (CI: 3.06-5.28, I2 = 92.88%), while NSF treated conservatively returned to play at 4.67 months (CI: 0.97-8.37, I2 = 99.46%) postoperatively, with no significant difference between operative and conservative management (SMD = - 0.397, CI: - 1.869-1.075, p = 0.60, I2 = 92.24). The pooled mean duration of symptoms before diagnosis was 9.862 (3.3-123.6) months (CI: 6.45-13.28, I2 = 94.92%), reported in ten studies. Twenty (23.53%) refractures were reported after conservative management of 85 NSFs, while one (1.28%) refracture was reported after operative management of 78 NSFs, with a significant difference in favor of operative management (OR = 0.083, CI: 0.007-0.973, p = 0.047, I2 = 38.78%). CONCLUSION: Operative management of NSF provides a higher success rate, a lower refracture rate, and a lower non-union rate as compared to other non-operative management options. While not significant, there is a notable trend towards superior RTP rates and time to RTP following operative management. Therefore, we recommend operative fixation for all NSFs type I through III in athletes. Athletes continue to exhibit an alarmingly long duration of symptoms before diagnosis is made; a high index of suspicion must be maintained, therefore, and adjunct CT imaging is strongly recommended in the case of any work-up. Unfortunately, the published literature on NSFs remains of lower level of evidence and high-quality studies are needed.

A cadaveric comparison of two methods for isolated talonavicular arthrodesis: Two-screws versus plate with integrated compression screw.

BACKGROUND: This study compared stiffness between two constructs for talonavicular arthrodesis: a dorsomedial plating system and two partially threaded cannulated cancellous screws. We hypothesized that the plate would exhibit greater stiffness and resistance to deformation during cyclic loading. METHODS: The constructs were implanted in eight matched pairs of cadaveric feet and subjected to axial torsion, cantilever bending in two directions, and cyclic loading to failure. RESULTS: The two-screw constructs were significantly stiffer in plantar-dorsal bending (p = .025) and trended towards a higher number of cycles before failure than the plate group (p = .087). No significant differences were observed in internal torsion (p = .620), external torsion (p = .165), or medial-lateral bending (p = .686). CONCLUSIONS: This study provided the first biomechanical assessment of a plating system with an integrated compression screw, which was significantly less stiff than a two-screw construct when loaded from plantar to dorsal.

Deficits of entropy modulation of the EEG: A biomarker for altered function in schizophrenia and bipolar disorder?

Background: The synchronized activity of distributed neural assemblies ­ reflected in the electroencephalogram (EEG) ­ underpins mental function. In schizophrenia, modulation deficits of EEG spectral content during a P300 task have been replicated. The effects of treatment, chronicity and specificity in these deficits and their possible relationship with anatomic connectivity remain to be explored. Methods: We assessed spectral entropy modulation of the EEG during a P300 task in 79 patients with schizophrenia (of those, 31 werein their first episode), 29 patients with bipolar disorder and 48 healthy controls. Spectral entropy values summarize EEG characteristics by quantifying the irregularity of spectral content. In a subsample, we calculated the network architecture of structural connectivity using diffusion tensor imaging and graph-theory parameters. Results: We found significant spectral entropy modulation deficits with task performance in patients with chronic or first-episode schizophrenia and in patients with bipolar disorder, without significant pre-stimulus spectral entropy differences. The deficits were unrelated to treatment doses, and spectral entropy modulation did not differ between patients taking or not taking antipsychotics, lithium, benzodiazepines or antidepressants. Structural connectivity values were unrelated to spectral entropy modulation. In patients with schizophrenia, spectral entropy modulation was inversely related to negative symptoms and directly related to verbal memory. Limitations: All patients were taking medication. Patients with bipolar disorder were euthymic and chronic. The cross-sectional nature of this study prevented a more thorough analysis of state versus trait criteria for spectral entropy changes. Conclusion: Spectral entropy modulation with task performance is decreased in patients with schizophrenia and bipolar disorder. This deficit was not an effect of psychopharmacological treatment or structural connectivity and might reflect a deficit in the synchronization of the neural assemblies that underlie cognitive activity.

Peroneal tendon dislocation in talus fracture and diagnostic value of fleck sign.

INTRODUCTION: Talus fractures are not uncommon and one of the serious fractures in the foot and ankle. Peroneal tendon dislocation is one of the commonly missed soft tissue injuries which may have significant impact on the outcomes including persistent pain and swelling. They have been reported to be associated with calcaneum as well as talus fractures. AIM: To report the incidence of peroneal tendon dislocation in talus fracture and the significance of fleck sign in the diagnosis of peroneal tendon dislocation. METHODS: We retrospectively reviewed 93 consecutive talus fractures in the period between 1/1/2011 to 1/11/2018. Inclusion criteria were: The patient underwent open reduction and internal fixation, had pre-operative CT scan that is available for review and three view ankle plain radiographs. Two independent authors review the radiographs for peroneal tendon dislocation, fleck sign and fracture classification, if any. Any dispute was resolved by the senior author.Patient records were reviewed for laterality, age, sex,mode of injury, associated injuries and operative interventions. 50 ankles met the inclusion criteria. 49 were males, mean age was 32.5 year and the predominant mode of injury was a fall from height. RESULTS: Peroneal tendon dislocation was found in ten patients out of 50 (20%). Risk of dislocation increased with severity of the fracture and neck fractures. Most of the dislocations were missed by surgeons and radiologist, and no additional procedures were done to address such an injury. The Fleck sign had a statistically significant correlation with peroneal tendons dislocations (p=.005) CONCLUSION: Peroneal tendons dislocation is associated with as high as 20% of talus fractures. The authors recommend carefully reviewing CT scans by surgeons and radiologists alike to avoid missing such injury and allow for appropriate surgical approach utilization. The Fleck sign is a highly specific radiographic sign that has a statistically significant correlation with PT dislocation and hence we recommend intra-operative assessment of peroneal tendons in patients with the fleck sign.

Outcome of primary deltoid ligament repair in acute ankle fractures: a meta-analysis of comparative studies.

PURPOSE: The indications of deltoid ligament repair in ankle injuries with widened medial clear space in the absence of medial malleolus fracture remain controversial. Many authors reported no difference in long-term functional outcomes, while others stated that persistent medial clear space widening and malreduction are higher when deltoid ligaments went without repair. This meta-analysis aims to report the current published evidence about the outcomes of deltoid ligament repair in ankle fractures. METHODS: Several databases were searched through May 2018 for comparative studies. The primary outcome was the medial clear space correction, while secondary outcomes included maintenance of medial clear space reduction, pain scores, functional outcome, and total complications if any. Three comparative studies met the inclusion criteria for the meta-analysis. The analysis included a total of 192 patients, 81 in the deltoid ligament repair group and 111 in the non-repair group. RESULTS: The medial clear space correction and maintenance of the said correction on final follow-up radiographs were superior in the deltoid ligament repair group. Although the pain scores were better in the repair group at the final follow-up, this did not result in a better functional outcome, with similar total complication rates. CONCLUSION: In conclusion, those who had their deltoid ligament repaired had superior early and late radiological correction of the medial clear space, an indicator of the quality of ankle reduction with better pain scores. However, no differences in the functional outcome and complications rate were reported.

International External Validation Study of the 2014 European Society of Cardiology Guidelines on Sudden Cardiac Death Prevention in Hypertrophic Cardiomyopathy (EVIDENCE-HCM).

BACKGROUND: Identification of people with hypertrophic cardiomyopathy (HCM) who are at risk of sudden cardiac death (SCD) and require a prophylactic implantable cardioverter defibrillator is challenging. In 2014, the European Society of Cardiology proposed a new risk stratification method based on a risk prediction model (HCM Risk-SCD) that estimates the 5-year risk of SCD. The aim was to externally validate the 2014 European Society of Cardiology recommendations in a geographically diverse cohort of patients recruited from the United States, Europe, the Middle East, and Asia. METHODS: This was an observational, retrospective, longitudinal cohort study. RESULTS: The cohort consisted of 3703 patients. Seventy three (2%) patients reached the SCD end point within 5 years of follow-up (5-year incidence, 2.4% [95% confidence interval {CI}, 1.9-3.0]). The validation study revealed a calibration slope of 1.02 (95% CI, 0.93-1.12), C-index of 0.70 (95% CI, 0.68-0.72), and D-statistic of 1.17 (95% CI, 1.05-1.29). In a complete case analysis (n= 2147; 44 SCD end points at 5 years), patients with a predicted 5-year risk of <4% (n=1524; 71%) had an observed 5-year SCD incidence of 1.4% (95% CI, 0.8-2.2); patients with a predicted risk of ≥6% (n=297; 14%) had an observed SCD incidence of 8.9% (95% CI, 5.96-13.1) at 5 years. For every 13 (297/23) implantable cardioverter defibrillator implantations in patients with an estimated 5-year SCD risk ≥6%, 1 patient can potentially be saved from SCD. CONCLUSIONS: This study confirms that the HCM Risk-SCD model provides accurate prognostic information that can be used to target implantable cardioverter defibrillator therapy in patients at the highest risk of SCD.

Clinical impact of direct stenting and interaction with thrombus aspiration in patients with ST-segment elevation myocardial infarction undergoing percutaneous coronary intervention: Thrombectomy Trialists Collaboration.

Aims: Preliminary studies suggest that direct stenting (DS) during percutaneous coronary intervention (PCI) may reduce microvascular obstruction and improve clinical outcome. Thrombus aspiration may facilitate DS. We assessed the impact of DS on clinical outcome and myocardial reperfusion and its interaction with thrombus aspiration among ST-segment elevation myocardial infarction (STEMI) patients undergoing PCI. Methods and results: Patient-level data from the three largest randomized trials on routine manual thrombus aspiration vs. PCI only were merged. A 1:1 propensity matched population was created to compare DS and conventional stenting. Synergy between DS and thrombus aspiration was assessed with interaction P-values in the final models. In the unmatched population (n = 17 329), 32% underwent DS and 68% underwent conventional stenting. Direct stenting rates were higher in patients randomized to thrombus aspiration as compared with PCI only (41% vs. 22%; P < 0.001). Patients undergoing DS required less contrast (162 mL vs. 172 mL; P < 0.001) and had shorter fluoroscopy time (11.1 min vs. 13.3 min; P < 0.001). After propensity matching (n = 10 944), no significant differences were seen between DS and conventional stenting with respect to 30-day cardiovascular death [1.7% vs. 1.9%; hazard ratio 0.88, 95% confidence interval (CI) 0.55-1.41; P = 0.60; Pinteraction = 0.96) and 30-day stroke or transient ischaemic attack (0.6% vs. 0.4%; odds ratio 1.02; 95% CI 0.14-7.54; P = 0.99; Pinteraction = 0.81). One-year results were similar. No significant differences were seen in electrocardiographic and angiographic myocardial reperfusion measures. Conclusion: Direct stenting rates were higher in patients randomized to thrombus aspiration. Clinical outcomes and myocardial reperfusion measures did not differ significantly between DS and conventional stenting and there was no interaction with thrombus aspiration.

Thrombus Aspiration in ST-Segment-Elevation Myocardial Infarction: An Individual Patient Meta-Analysis: Thrombectomy Trialists Collaboration.

BACKGROUND: Thrombus aspiration during percutaneous coronary intervention (PCI) for the treatment of ST-segment-elevation myocardial infarction (STEMI) has been widely used; however, recent trials have questioned its value and safety. In this meta-analysis, we, the trial investigators, aimed to pool the individual patient data from these trials to determine the benefits and risks of thrombus aspiration during PCI in patients with ST-segment-elevation myocardial infarction. METHODS: Included were large (n≥1000), randomized, controlled trials comparing manual thrombectomy and PCI alone in patients with ST-segment-elevation myocardial infarction. Individual patient data were provided by the leadership of each trial. The prespecified primary efficacy outcome was cardiovascular mortality within 30 days, and the primary safety outcome was stroke or transient ischemic attack within 30 days. RESULTS: The 3 eligible randomized trials (TAPAS [Thrombus Aspiration During Percutaneous Coronary Intervention in Acute Myocardial Infarction], TASTE [Thrombus Aspiration in ST-Elevation Myocardial Infarction in Scandinavia], and TOTAL [Trial of Routine Aspiration Thrombectomy With PCI Versus PCI Alone in Patients With STEMI]) enrolled 19 047 patients, of whom 18 306 underwent PCI and were included in the primary analysis. Cardiovascular death at 30 days occurred in 221 of 9155 patients (2.4%) randomized to thrombus aspiration and 262 of 9151 (2.9%) randomized to PCI alone (hazard ratio, 0.84; 95% confidence interval, 0.70-1.01; P=0.06). Stroke or transient ischemic attack occurred in 66 (0.8%) randomized to thrombus aspiration and 46 (0.5%) randomized to PCI alone (odds ratio, 1.43; 95% confidence interval, 0.98-2.10; P=0.06). There were no significant differences in recurrent myocardial infarction, stent thrombosis, heart failure, or target vessel revascularization. In the subgroup with high thrombus burden (TIMI [Thrombolysis in Myocardial Infarction] thrombus grade ≥3), thrombus aspiration was associated with fewer cardiovascular deaths (170 [2.5%] versus 205 [3.1%]; hazard ratio, 0.80; 95% confidence interval, 0.65-0.98; P=0.03) and with more strokes or transient ischemic attacks (55 [0.9%] versus 34 [0.5%]; odds ratio, 1.56; 95% confidence interval, 1.02-2.42, P=0.04). However, the interaction P values were 0.32 and 0.34, respectively. CONCLUSIONS: Routine thrombus aspiration during PCI for ST-segment-elevation myocardial infarction did not improve clinical outcomes. In the high thrombus burden group, the trends toward reduced cardiovascular death and increased stroke or transient ischemic attack provide a rationale for future trials of improved thrombus aspiration technologies in this high-risk subgroup. CLINICAL TRIAL REGISTRATION: URLs: http://www.ClinicalTrials.gov http://www.crd.york.ac.uk/prospero/. Unique identifiers: NCT02552407 and CRD42015025936.

Prevalence of Peroneal Tendon Instability in Calcaneus Fractures: A Systematic Review and Meta-Analysis.

Peroneal tendon instability associated with an intraarticular calcaneal fracture is a common injury that still often passes undiscovered by both radiologists and orthopedic surgeons. Timely identification of this injury will guide the choice of surgical technique used and treatment of patients. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, several databases were searched through June 2017 for any observational or experimental studies that reported the prevalence/incidence of peroneal tendon subluxation/dislocation with a calcaneus fracture with regard to fracture classifications and the significance of the fleck sign. Nine studies were included, with 1027 patients and 1050 calcaneus fractures. The overall prevalence of peroneal instability (PI) in association with a calcaneus fracture was 29.3%. An increasing prevalence of PI increased the severity of the calcaneus fractures, 5.4% in Sanders I, 19% in Sanders II, 39.4% in Sanders III, and 49.5% in Sanders IV. The presence of a fleck sign is a strong indicator of PI, with a prevalence of 54.7%. The computed tomography findings can overestimate the presence of PI compared with the intraoperative findings. The global reported prevalence of peroneal tendon instability associated with intraarticular calcaneal fractures is high and increases with increasing severity of the calcaneus fracture.

US Medical Schools' Awareness of Their Students Who Smoke, Cessation Programs Available, and the Potential Impact on Residency Match.

INTRODUCTION: Hospital systems are adopting strict nicotine-free policies excluding hiring individuals who smoke, including residents for graduate medical training. This study was conducted to (1) determine medical schools' awareness of these policies, (2) awareness of their students' smoking behaviors, and (3) the smoking cessation programs that they provide. METHODS: A survey was developed to learn about the smoking policies of medical schools in the United States: how school leadership estimates smoking prevalence among their students, what those estimates are, and what programs are in place to help students quit smoking. Questions were asked about awareness of policies restricting hiring smokers including applicants for residency training. Opinions were solicited on including smoking status in medical school applications. The online survey was sent to the Deans of student affairs at US medical schools. RESULTS: Of the 160 schools invited to participate, 84 (53%) responded. Most medical schools (92%) are smoke-free and 97% have policies specifically prohibiting tobacco use on campus. Estimates of student smoking prevalence varied from 0% to 34% with a mean of 6%. More than half of schools (52%) had no smoking-cessation programs to help students. Despite recent trends in policies that prohibit smokers from being hired into residency training programs, only 22% were aware of such policies. There were no statistically significant differences by school size, location or category (allopathic, osteopathic, public or private). CONCLUSIONS: Medical schools need to be aware of new hiring policies and take steps to identify and help their students quit smoking to ensure all students can secure residency training upon graduation. IMPLICATIONS: This study draws attention to recent policies that preclude hiring medical students who smoke for post graduate (residency) training. Our study demonstrates a lack of appreciation of these policies by medical school administration in the United States. Our study also provides information on smoking rates of medical students, as well as the prevalence and use of smoking cessation programs available through schools of medicine. The study supports the need for medical schools to identify and aid students who smoke to become nicotine-free so that they can secure residency training positions.

Right-sided endocarditis: eustachian valve and coronary sinus involvement.

Infective endocarditis in patients with intravenous drug use commonly involves right-sided heart valves. Eustachian valve (EV) endocarditis is not commonly seen given the valve's infrequent presence. Involvement of the coronary sinus (CS) with endocarditis is also an unusual finding. We present a case with echocardiographic findings consistent with EV endocarditis along with CS involvement, which appropriately responded to antibiotics.

Association between electroencephalographic modulation, psychotic-like experiences and cognitive performance in the general population.

AIM: An association between deficit of electroencephalographic (EEG) modulation during an odd-ball task and psychotic symptoms has been described in clinical samples, in agreement with the proposed role for altered salience in psychosis. To discard the possible influence of medication, the relationship between psychotic-like experiences and EEG modulation in the general population was explored. METHODS: EEG and psychotic-like experiences were assessed in 194 healthy subjects during a P300 paradigm. EEG modulation was assessed as changes from pre-stimulus to response windows in spectral entropy (SE, a measurement of signal irregularity), median frequency (MF, a quantifier of the frequency distribution of oscillatory activity) and theta, alpha, beta-1, beta-2 and gamma relative power (RP, a summary of the distribution of spectral components). RESULTS: A significant widespread decrease in SE and MF from baseline to response was found, with a significant increase in RP for theta and a decrease for higher frequency bands, supporting an increase in EEG regularity and a slowing of brain oscillations during the response. Furthermore, a significant association was found between SE modulation and distress of negative psychotic-like experiences, as well as between verbal memory and RP modulation for beta-1. Performance in verbal fluency was associated with the increase in theta RP during the response. CONCLUSION: EEG irregularity of healthy subjects decreased at the expense of a larger contribution of theta RP and a decreased contribution of fast frequency bands. Subjects with smaller modulation showed poorer cognitive scores and greater distress of negative psychotic-like experiences.

Prevalence, consequences and predictors of low back pain among nurses in a tertiary care setting.

PURPOSE: Nursing is a profession with high incidence and prevalence of low back pain (LBP), with its medical and professional consequences. These prevalence rates vary among countries, and with various measurements have been used to determine LBP. Individual and work-related factors are regarded as causal factors for many back injuries. The aims of study this were: (1) to estimate the prevalence of LBP using different measures, (2) to determine medical and professional consequences of LBP, and (3) to determine the associated factors and significant predictors of LBP. METHODS: A cross-sectional study was conducted among 254 nurses from different departments/wards at Hamad General Hospital (HGH), Doha, Qatar over two months (February and March, 2015). A self-administered modified Nordic questionnaire was used to collect data regarding five different measures of LBP, its medical and occupational consequences and individual/lifestyle and work-related risk factors of LBP. Descriptive and analytic statistical analyses were done using chi-square and multivariate logistic regression techniques. Significance was considered at p ≤ 0.05. RESULTS: The findings of this study broadly confirm the high levels of back pain in nursing, with a one-year prevalence of LBP of 54.3 % for LBP of at least one day, 26.8 % for chronic LBP, 18.1 % for sick leave seeking LBP, and 34.3 % for medical treatment seeking LBP. Difficult or impossible activities of daily living were reported due to LBP in climbing stairs (50.7 %), walking (42.8 %), standing up (39.9 %), sleeping (33.3 %), getting out of bed (30.4 %) and wearing clothes (20.3 %). Work stop due to LBP was reported by 76.8 % of nurses, with 2.03 ± 3.09 days within the last year. Treatment was sought in 58.7 % by medical care, and 15.9 % by physiotherapy, while seeking rest days and/or sick leave was sought in 50.8 % of nurses with LBP. Sports practice (p = 0.003), office work (p < 0.001) and exposure to physical stress (p = 0.002) were the only significant predictors of LBP among nurses, when logistic regression analysis was conducted. CONCLUSION: The prevalence of LBP among nurses at HGH is high and should be actively addressed, however, it was not a major cause of sick leave. Preventive measures should be taken to reduce the risk of lower back pain, such as arranging proper rest periods, educational programs to teach the proper use of body mechanics and sports activity programs.

Acute Isolated Right Ventricular Infarction.

The electrocardiogram is universally used to diagnose ST-segment elevation myocardial infarction and serves as guidance for the interventional cardiologist to identify the acute thrombotic lesion. However, this case illustrates that the electrocardiogram can also be deceiving.