The Importance of Pragmatic Study Design to the Scholarly Influence of Surgical Hip Fracture Randomized Controlled Trials.

BACKGROUND: Surgical randomized controlled trials (RCTs) have potential drawbacks, leading some to question their role in filling the information gap in orthopaedic surgery. Pragmatism in study design was introduced to increase the clinical applicability of study results. The purpose of this study was to examine how pragmatism affects the scholarly influence of surgical RCTs. METHODS: A search for surgical hip fracture-related RCTs published between 1995 and 2015 was done. Journal impact factor, citation number, research question, significance and type of outcome, number of centers involved, and the Pragmatic-Explanatory Continuum Indicator Summary-2 level of pragmatism score were recorded for each study. Scholarly influence was estimated by a study's inclusion into orthopaedic literature or guidelines or through the study's average yearly citation rate. RESULTS: One hundred sixty RCTs were included in the final analysis. A multivariate logistic regression identified large study sample size as the only predictor of an RCT being used in clinical guidance texts. Large sample size and multicenter RCTs were predictors of high yearly citation rates. The level of pragmatism in study design did not predict scholarly influence. CONCLUSIONS: Pragmatic design is not independently associated with increased scholarly influence; however, large study sample size was the most important study characteristic affecting scholarly influence.

Case Report: Infective Endocarditis of Mechanical Aortic Valve Due to Neisseria elongata Bacteremia.

BACKGROUND Neisseria elongata is a infrequent cause of infective endocarditis (IE). Although considered a commensal bacterium of the human nasopharynx, N. elongata has been shown to be the cause of significant disease in humans, namely endocarditis, osteomyelitis, and septicemia. CASE REPORT We report the case of a 53-year-old man with a past medical history of mechanical aortic valve who presented to the hospital for evaluation of eleven days of recurrent and relapsing fevers and was admitted for severe sepsis with concern for endocarditis. Blood cultures revealed N. elongata bacteremia, and an echocardiogram did not show any vegetations, although it was limited by mechanical aortic valve shadowing. The patient recovered after six weeks of treatment with intravenous ceftriaxone and oral ciprofloxacin. CONCLUSIONS Clinicians should be aware of the possibility of the previously considered non-pathogenic N. elongata as a source of IE caused by gram-negative organisms, as it can potentially cause severe disease and multiple complications. Our case additionally highlights that IE has highly variable clinical presentations. Thus, it is essential to utilize the Duke criteria as only a clinical guide for the diagnosis of IE rather than a substitute for clinical judgment and the decision to treat a patient with suspected IE.

Clinical presentation and management of myocardial infarction with nonobstructive coronary arteries (MINOCA): A literature review.

Myocardial Infarction with Nonobstructive Coronary Arteries (MINOCA), as the name implies, is an acute myocardial infarction (MI) in the absence of significant coronary artery obstruction. Diagnosis and management of such cases have been challenging. There are many etiologies of MINOCA including coronary artery spasm, coronary microvascular dysfunction, plaque disruption, spontaneous coronary thrombosis or emboli, spontaneous coronary artery dissection, or cardiomyopathies. In this paper, the pathophysiology, diagnostic work-up, and clinical management for each subtype are described, and an overarching approach on how to evaluate and manage a patient presenting with MINOCA.