Borgess Health

The centrality of data in modern society has prompted a need to examine the increasingly powerful role of data brokers and their efforts to quantify the world. Practices and methods such as surveillance, biometrics, automation, data creeping, or profiling consumer behaviour, all offer opportunities and challenges to news reporting. Nonetheless, as most professional journalists display a degree of hesitancy towards numbers and computational literacy, there are only limited means to investigate the power dynamics underpinning data. This article discusses the extent to which current data journalism practices in the United Kingdom employ databases and algorithms as a means of holding data organisations accountable. Drawing on semi-structured interviews with data journalists, data editors, and news managers working for British mainstream media, the study looks at how data journalism operates within the news cycle of professional newsrooms in the United Kingdom. Additionally, it examines the innovations data journalism brings to storytelling, newsgathering, and the dissemination of news.

PURPOSE: To optimize artificial intelligence (AI) algorithms to integrate Scheimpflug-based corneal tomography and biomechanics to enhance ectasia detection. DESIGN: Multicenter cross-sectional case-control retrospective study. METHODS: A total of 3886 unoperated eyes from 3412 patients had Pentacam and Corvis ST (Oculus Optikgeräte GmbH) examinations. The database included 1 eye randomly selected from 1680 normal patients (N) and from 1181 "bilateral" keratoconus (KC) patients, along with 551 normal topography eyes from patients with very asymmetric ectasia (VAE-NT), and their 474 unoperated ectatic (VAE-E) eyes. The current TBIv1 (tomographic-biomechanical index) was tested, and an optimized AI algorithm was developed for augmenting accuracy. RESULTS: The area under the receiver operating characteristic curve (AUC) of the TBIv1 for discriminating clinical ectasia (KC and VAE-E) was 0.999 (98.5% sensitivity; 98.6% specificity [cutoff: 0.5]), and for VAE-NT, 0.899 (76% sensitivity; 89.1% specificity [cutoff: 0.29]). A novel random forest algorithm (TBIv2), developed with 18 features in 156 trees using 10-fold cross-validation, had a significantly higher AUC (0.945; DeLong, P < .0001) for detecting VAE-NT (84.4% sensitivity and 90.1% specificity; cutoff: 0.43; DeLong, P < .0001) and a similar AUC for clinical ectasia (0.999; DeLong, P = .818; 98.7% sensitivity; 99.2% specificity [cutoff: 0.8]). Considering all cases, the TBIv2 had a higher AUC (0.985) than TBIv1 (0.974; DeLong, P < .0001). CONCLUSIONS: AI optimization to integrate Scheimpflug-based corneal tomography and biomechanical assessments augments accuracy for ectasia detection, characterizing ectasia susceptibility in the diverse VAE-NT group. Some patients with VAE may have true unilateral ectasia. Machine learning considering additional data, including epithelial thickness or other parameters from multimodal refractive imaging, will continuously enhance accuracy. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.

BACKGROUND: Lower extremity injuries are the most common injuries in professional sports and carry a high burden to players and teams in the National Football League (NFL). Injury prevention strategies can be refined by a foundational understanding of the occurrence and effect of these injuries on NFL players. PURPOSE: To determine the incidence of specific lower extremity injuries sustained by NFL players across 4 NFL seasons. STUDY DESIGN: Descriptive epidemiology study. METHODS: This retrospective, observational study included all time-loss lower extremity injuries that occurred during football-related activities during the 2015 through 2018 seasons. Injury data were collected prospectively through a leaguewide electronic health record (EHR) system and linked with NFL game statistics and player participation to calculate injury incidence per season and per 10,000 player-plays for lower extremity injuries overall and for specific injuries. Days lost due to injury were estimated through 2018 for injuries occurring in the 2015 to 2017 seasons. RESULTS: An average of 2006 time-loss lower extremity injuries were reported each season over this 4-year study, representing a 1-season risk of 41% for an NFL player. Incidence was stable from 2015 to 2018, with an estimated total missed time burden each NFL season of approximately 56,700 player-days lost. Most (58.7%) of these injuries occurred during games, with an overall higher rate of injuries observed in preseason compared with regular season (11.5 vs 9.4 injuries per 10,000 player-plays in games). The knee was the most commonly injured lower extremity region (29.3% of lower body injuries), followed by the ankle (22.4%), thigh (17.2%), and foot (9.1%). Hamstring strains were the most common lower extremity injury, followed by lateral ankle sprains, adductor strains, high ankle sprains, and medial collateral ligament tears. CONCLUSION: Lower extremity injuries affect a high number of NFL players, and the incidence did not decrease over the 4 seasons studied. Prevention and rehabilitation protocols for these injuries should continue to be prioritized.

BACKGROUND: The published long-term follow-up of modern total ankle arthroplasty is limited. We report results after a minimum of 10-year follow-up in a cohort of patients who underwent the Scandinavian Total Ankle Replacement (STAR™) in the United States. METHODS: Between 1998 and 2003, 18 patients underwent total ankle arthroplasty for end-stage ankle degeneration and were available for follow-up at a minimum of 10 years postoperatively out of a consecutive series of 41 patients. All surgeries were performed by a single surgeon at a single institution. Clinical, radiographic, and functional examinations were performed. Revision was defined as failure of either the tibial or the talar metallic component. The mean length of follow-up was 12.6 years (range, 10.2 to 14.6). RESULTS: Overall implant survival was 94.4% (17/18). A total of 39% (7/18) required additional surgical procedures, most of which were performed greater than 9 years postoperatively, and 1 required a revision of the prosthesis. Preoperative VAS pain scale scores improved from 8.1 to 2.1 out of 10 at latest follow-up. Mean Buechel-Pappas Scale scores improved from 32.8 to 82.1 and mean AOFAS Ankle-Hindfoot Scale scores improved from 32.8 to 78.1 at latest follow-up. All patients reported their outcome as good or excellent. CONCLUSION: In the current cohort of STAR ankle patients, implant survival, patient satisfaction, pain relief, and function were high. However, the rate of additional procedures was also high, which highlights the need for patient follow-up and additional long-term outcome studies on total ankle arthroplasty. LEVEL OF EVIDENCE: Level IV, cohort study.

BACKGROUND: Both total ankle arthroplasty (TAA) and ankle arthrodesis are options for the treatment of ankle arthritis and have been shown to improve gait postoperatively. Little is known about the postoperative performance of these patients on uneven surfaces. METHODS: Between 2010 and 2013, 77 consecutive patients were enrolled in a prospective study and completed 12 months of follow-up. Patients received either a TAA (61 patients) or an ankle arthrodesis (16 patients). Preoperatively, at 6 months and 12 months postoperatively, patients were evaluated clinically and functionally on stairs, an inclined ramp, and an uneven surface. Patients graded their function on these surfaces using a visual analog scale (VAS) in addition to standard clinical grading scales. RESULTS: There was no statistically significant difference between the patient groups preoperatively (all P > .05). Both TAA and ankle arthrodesis groups had high patient satisfaction, 3.5 and 3.4 out of 4.0, respectively. Both groups had improvement in Buechel-Pappas scores, VAS pain scores, AOFAS Ankle Hindfoot scores, and functional scores (all P values < .05). TAA patients had a significantly better outcome than the arthrodesis patients in the Buechel-Pappas scale (P = .036), AOFAS Ankle Hindfoot score (P = .03), ankle dorsiflexion (P < .001), ankle plantarflexion (P < .001), walking upstairs (P = .013), walking downstairs (P = .012), and walking uphill (P = .016). CONCLUSIONS: Patients with TAA and ankle arthrodesis had improved performance walking on uneven surfaces at 12 months of follow-up compared to preoperatively. TAA patients had higher scores than the ankle arthrodesis patients walking upstairs, downstairs, and uphill. LEVEL OF EVIDENCE: Level II, prospective cohort study.

BACKGROUND AND PURPOSE: It is important to try to clarify the methodology of vertebroplasty such as amount of cement needed, how many needles to use and the significance of cement extravasation. This prospective study evaluated the potential of vertebroplasty to increase the likelihood of an adjacent vertebral compression fracture (VCF) 1 year or less after vertebroplasty, the correlation between the cement volumes injected and pain relief, and the consequences of cement extravasation. MATERIALS AND METHODS: Pain relief and the incidence of a subsequent fracture of adjacent vertebrae 1 year or less after vertebroplasty were evaluated in 357 patients (660 vertebrae) of mean age 77.5 years with osteoporotic VCFs. The correlation between cement volume and pain relief was assessed with a Pearson correlation coefficient; factors potentially predictive of subsequent adjacent VCFs were explored by multiple logistic regression analysis. RESULTS: Refracture of any vertebrae (adjacent or nonadjacent to the primary fracture) occurred in 18% of the patients 1 year or less after vertebroplasty. Refracture of adjacent vertebrae occurred 1 year or less after vertebroplasty in 12% of the patients. Neither cement volume nor extravasation of cement into the intravertebral disk was a significant predictor of adjacent VCFs. No correlation was found between cement volume and pain relief (r = -0.029). Extravasation of cement into the veins, soft tissue, or disk was observed in 33% of all of the treated VCFs and resulted in no complications. CONCLUSIONS: The incidence of an adjacent VCF 1 year or less after vertebroplasty was comparable with that expected for untreated osteoporotic VCFs. Neither the volume of cement injected nor extravasation of cement into the intravertebral disk affected the likelihood of subsequent adjacent VCFs. Cement volume did not correlate with pain relief.

BACKGROUND: Femur fractures are common among trauma patients and are typically seen in patients with multiple injuries resulting from high-energy mechanisms. Internal fixation with intramedullary nailing is the ideal method of treatment; however, there is no consensus regarding the optimal timing for internal fixation. We critically evaluated the literature regarding the benefit of early (<24 hours) versus late (>24 hours) open reduction and internal fixation of open or closed femur fractures on mortality, infection, and venous thromboembolism (VTE) in trauma patients. METHODS: A subcommittee of the Practice Management Guideline Committee of the Eastern Association for the Surgery of Trauma conducted a systematic review and meta-analysis for the earlier question. RevMan software was used to generate forest plots. Grading of Recommendations, Assessment, Development, and Evaluations methodology was used to rate the quality of the evidence, using GRADEpro software to create evidence tables. RESULTS: No significant reduction in mortality was associated with early stabilization, with a risk ratio (RR) of 0.74 (95% confidence interval [CI], 0.50-1.08). The quality of evidence was rated as "low." No significant reduction in infection (RR, 0.4; 95% CI, 0.10-1.6) or VTE (RR, 0.63; 95% CI, 0.37-1.07) was associated with early stabilization. The quality of evidence was rated "low." CONCLUSION: In trauma patients with open or closed femur fractures, we suggest early (<24 hours) open reduction and internal fracture fixation. This recommendation is conditional because the strength of the evidence is low. Early stabilization of femur fractures shows a trend (statistically insignificant) toward lower risk of infection, mortality, and VTE. Therefore, the panel concludes the desirable effects of early femur fracture stabilization probably outweigh the undesirable effects in most patients.

BACKGROUND: Lesser metatarsophalangeal (MTP) joint instability is a common cause of forefoot pain. Advances in operative technique and instrumentation have made it possible to anatomically treat plantar plate tears through a dorsal approach. Our goal was to evaluate the subjective, functional, and radiographic outcomes of plantar plate repair (PPR) from a dorsal approach. METHODS: A prospective case series was performed evaluating the results of PPR in 97 feet with 138 plantar plate tears. Patients underwent PPR from a dorsal approach with a Weil osteotomy. We followed patients at regular intervals for 12 months and collected data preoperatively and postoperatively with respect to visual analog scale (VAS) scores, MTP range of motion (ROM), paper pull-out test, American Orthopaedic Foot & Ankle Society (AOFAS) scores, satisfaction, and radiographic measures. RESULTS: Eighty percent of patients scored "good" to "excellent" satisfaction scores at 12 months. The mean VAS pain score preoperatively was 5.4/10, and postoperatively was 1.5/10. The mean AOFAS scores increased from 49 to 81 points following surgery. The mean MTP ROM preoperatively was 43 degrees and postoperatively 31 degrees. Forty-two percent of toes passed the paper pull out test prior to surgery and 54% at 12 months. Mean metatarsal shortening was 2.4/3.1/1.2 mm for the second, third, and fourth metatarsals, respectively. The mean MTP joint angles preoperatively were 2/4.9/-1.3 degrees and postoperatively were 7.4/9.6/0.2 degrees, respectively, for the second, third, and fourth MTP joints. CONCLUSION: We found that the plantar plate could be repaired through a dorsal approach with reliable outcomes. PPR was a viable option to anatomically restore the ligamentous support in the unstable lesser MTP joint. LEVEL OF EVIDENCE: Level IV, retrospective case series.

This year marks the fifth anniversary of West Michigan Air Care, the first merged, hospital-based air medical program in the United States. This milestone is being observed with a certain satisfaction that comes from achieving what others said "couldn't be done."

BACKGROUND: Studies have shown that response to a given chemotherapy in previously untreated patients with extensive-stage small-cell lung cancer is superior to that in patients previously treated with other regimens. This finding raises the question of whether it is necessary and ethical to study the effects of new anticancer agents in untreated patients. Such studies appear to be the best test for drug development, but there has been no evaluation of whether survival of untreated patients, whose cancer is sensitive to established drugs, is adversely affected in trials of new drugs. PURPOSE: This randomized study of untreated patients with extensive-stage small-cell lung cancer was designed (a) to compare the survival of patients treated with either effective standard chemotherapy or an investigational anticancer drug as initial therapy and (b) to evaluate response rates and toxic effects of such therapies. METHODS: Eighty-six patients were randomly assigned to receive, as initial therapy, either the standard CAV regimen--cyclophosphamide (1000 mg/m2), doxorubicin (50 mg/m2), and vincristine (1.4 mg/m2) every 3 weeks--or the phase II drug menogaril (200 mg/m2) every 4 weeks. Treatment after induction therapy varied, depending on patient response, but nonresponders and those with disease progression received salvage chemotherapy--etoposide (120 mg/m2 on days 1, 2, and 3) and cisplatin (60 mg/m2 on day 1), repeated every 3 weeks. RESULTS: Of the 43 patients on CAV, 42% responded (eight complete responses and 10 partial responses); 5% of the 43 on menogaril responded (two partial responses) (P = .0001). Twelve (22%) of 54 patients responded to salvage chemotherapy (five complete responses and seven partial responses). Within 3 months from start of treatment, twelve patients died--3 patients in the CAV group and nine patients in the menogaril group (P = .12). The estimated median survival was 37 weeks with menogaril and 45 weeks with CAV (P = .28). At 6 months, survival was 76.7% for the CAV group and 67.4% for the menogaril group. At 12 months, survival rates were 24.4% and 27.9%, respectively. Confidence intervals (95%) for the differences between the proportions surviving in the two groups were -9%-28% at 6 months and -25%-14% at 12 months. Use of CAV resulted in significantly higher occurrence of severe and life-threatening treatment-related complications (P = .002). CONCLUSION: The confidence intervals for the differences in survival are too wide to conclude that evaluation of a new drug in untreated patients with extensive-stage small-cell lung cancer is or is not harmful. The data do suggest, however, that use of this study design may have no adverse effect on survival.

BACKGROUND: An understanding of whether homocysteine is a cause or a marker of increased blood pressure is relevant because blood homocysteine can be effectively lowered by safe and inexpensive interventions (e.g., vitamin B-6, B-9, and B-12 supplementation). OBJECTIVE: The aim was to assess the causal influence of homocysteine on systolic and diastolic blood pressure (SBP and DBP, respectively) in adults with the use of Mendelian randomization (MR). DESIGN: Data from the 1982 Pelotas Birth Cohort (Brazil) were used. A total of 4297 subjects were evaluated in 2004-2005 (mean age: 22.8 y). The association of homocysteine concentration with SBP and DBP was assessed by conventional ordinary least-squares (OLS) linear regression and 2-stage least-squares (2SLS) regression (MR analysis). The single nucleotide polymorphism (SNP) methylenetetrahydrofolate reductase (MTHFR) C677T (rs1801133) was used as proxy for homocysteine concentration. We also applied MR to data from the International Consortium for Blood Pressure (ICBP) genomewide association studies (>69,000 participants) using rs1801133 and additional homocysteine-associated SNPs as instruments. RESULTS: In OLS regression, a 1-SD unit increase in log homocysteine concentration was associated with an increase of 0.9 (95% CI: 0.4, 1.4) mm Hg in SBP and of 1.0 (95% CI: 0.6, 1.4) mm Hg in DBP. In 2SLS regression, for the same increase in homocysteine, the coefficients were -1.8 mm Hg for SBP (95% CI: -3.9, 0.4 mm Hg; P = 0.01) and 0.1 mm Hg for DBP (95% CI: -1.5, 1.7 mm Hg; P = 0.24). In the MR analysis of ICBP data, homocysteine concentration was not associated with SBP (β = 0.6 mm Hg for each 1-SD unit increase in log homocysteine; 95% CI: -0.8, 1.9 mm Hg) but was positively associated with DBP (β = 1.1 mm Hg; 95% CI: 0.2, 1.9 mm Hg). The association of genetically increased homocysteine with DBP was not consistent across different SNPs. CONCLUSION: Overall, the present findings do not corroborate the hypothesis that homocysteine has a causal role in blood pressure, especially in SBP.

BACKGROUND: Subtalar arthrodesis is a common treatment for end-stage subtalar joint arthritis as well as many other clinical problems. The best method of subtalar arthrodesis fixation is unknown. The purpose of this study was to compare the strength of subtalar arthrodesis fixation methods including a single posterior screw (SP), 2 posterior minimally divergent screws (MD) and a 2 screw highly divergent screw (HD) construct for subtalar arthrodesis. METHODS: A biomechanical study was performed including the three different screw configurations (SP, MD, HD). These surrogate bone specimens were subjected to applied inversion and eversion torques about the subtalar joint axis on a servo-hydraulic load frame. Torsional stiffness of the construct and the maximum torque for each configuration were measured. Additionally, a cadaver study was performed using 5 fresh-frozen cadaver specimens. The perpendicular distance from the divergent screw guide-wire placement was measured from anatomic structures. RESULTS: The HD screw configuration was found to have the highest torsional stiffness in both inversion and eversion, followed by the MD construct and then the SP construct. Similarly, the HD construct had the highest maximum torque versus the MD and SP constructs. All between-group differences were statistically significant (P < .05). The mean distance from key structures to the divergent screw included the sural nerve (13 mm), peroneus brevis tendon (18 mm), tibialis anterior tendon (8 mm), and tibialis posterior tendon (21 mm). CONCLUSION: This biomechanical and cadaver study supports the use of 2 screws for fixation of subtalar arthrodesis over a single posterior screw. Additionally, we describe a biomechanically superior and potentially safe, alternative 2-screw divergent construct. CLINICAL RELEVANCE: This study gives biomechanical support for 2 screw, divergent fixation of subtalar arthrodesis or a single over a single screw or two screw minimally divergent construct.

INTRODUCTION: Patients with obstructive sleep apnea-hypopnea syndrome (OSAHS) often have associated changes in craniofacial morphology and distribution of body fat, either alone or in combination. AIM: To correlate cephalometric and anthropometric measures with OSAHS severity by using the apnea-hypopnea index (AHI). METHOD: A retrospective cephalometry study of 93 patients with OSAHS was conducted from July 2010 to July 2012. The following measurements were evaluated: body mass index (BMI), neck circumference (NC), waist circumference (WC), hip circumference (HC), the angles formed by the cranial base and the maxilla (SNA) and the mandible (SNB), the difference between SNA and SNB (ANB), the distance from the mandibular plane to the hyoid bone (MP-H), the space between the base of the tongue and the posterior pharyngeal wall (PAS), and the distance between the posterior nasal spine and the tip of the uvula (PNS-P). Means, standard deviations, and Pearson's correlation coefficients were calculated and analyzed. RESULTS: AHI correlated significantly with BMI (r = 0.207, p = 0.047), NC (r = 0.365, p = 0.000), WC (r = 0.337, p = 0.001), PNS-P (r = 0.282, p = 0.006), and MP-H (r = 0.235, p = 0.023). CONCLUSION: Anthropometric measurements (BMI, NC, and WC) and cephalometric measurements (MP-H and PNS-P) can be used as predictors of OSAHS severity.

BACKGROUND: Several studies report performing a recession of the gastrocnemius tendon as surgical treatment of foot and ankle pain related to an isolated gastrocnemius contracture. Few report ankle range of motion using a validated measurement device or report a control group. All previous studies reporting measurements using a validated device have been small in number. METHODS: Using a previously validated device, 66 patients presenting with foot or ankle pain and 66 controls were measured for ankle range of motion and isolated gastrocnemius contractures. Clinical and goniometer measurement of ankle range of motion was also performed. RESULTS: The foot and ankle pain group had a mean dorsiflexion of 11.6 degrees compared with a mean of 17.2 degrees in the control group (P < .0001). No patients in either group had less than 15 degrees of motion with the knee flexed. The difference in dorsiflexion was less using a goniometer than using the validated device, which may be due to measurement technique and external landmarks. CONCLUSION: Patients with foot and ankle pain had less ankle dorsiflexion than the control group. This is the largest study to date using a validated measurement device as well as a control group and supports the findings of previous authors. LEVEL OF EVIDENCE: Level II, prospective cohort study.

BACKGROUND: This systematic review aimed to present an updated analysis of the evidence comparing outcomes between robotic-assisted total hip arthroplasty (robotic THA) and conventional manual total hip arthroplasty (manual THA). METHODS: A PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) systematic review was performed using the Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, PubMed, MEDLINE, and Embase. Controlled studies comparing primary robotic THA and manual THA utilizing patient-reported outcome measures (PROMs) at a minimum follow-up of 2 years were included. We also compared radiographic outcomes, dislocation rates, and revision surgical procedures between groups. The ROBINS-I (Risk of Bias in Non-Randomized Studies - of Interventions) and Cochrane Risk of Bias 2.0 tools were used to assess study quality and risk of bias. RESULTS: Of 765 studies identified, 7 articles comparing robotic THA with manual THA met inclusion criteria. A total of 658 patients were assessed, 335 of whom underwent robotic THA. The majority of studies found no significant differences (p > 0.05) in PROMs between the 2 techniques. Two low-quality studies (Level III) found significantly better postoperative PROMs favoring robotic THA at 2 years. When assessing radiographic outcomes, 6 studies showed that robotic THA resulted in more consistent and accurate component placement. No differences in postoperative dislocations, complications, or revision rates were found between groups except in 1 study, which found significantly more dislocations and revisions in the robotic THA cohort. Reported operative times were a mean of 12 to 25 minutes longer when using robotic THA. CONCLUSIONS: The existing literature comparing robotic THA and manual THA is scarce and low-quality, with findings limited by methodological flaws in study design. Although evidence exists to support increased accuracy and reproducibility of THA component placement with robotic THA, this has not been shown to reduce postoperative dislocation and revision rates. Based on the available evidence, functional outcomes are comparable between techniques, and robotic THA appears to be associated with longer operative times. To fully evaluate the utility of robotic THA, additional well-designed, prospective controlled studies with continuous long-term monitoring are required. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND AND PURPOSE: Recent recommendations call for in-hospital initiation of lipid-lowering therapy (LLT) for most ischemic stroke (IS) and transient ischemic attack (TIA) survivors; however, little is known about actual use. This study describes use of and predictors for in-hospital lipid testing and LLT using data from a statewide stroke registry. METHODS: In 2002, the registry ascertained cases from a stratified sample of 16 hospitals. This study includes only IS and TIA cases discharged alive. RESULTS: In 1907 study subjects, 30.2% (27.2% to 33.5%) were on LLT at admission. In 1399 subjects not on LLT at admission, 37.2% (30.2% to 44.9%) underwent lipid testing, and 12.9% (7.2% to 22.1%) received LLT at discharge. Use of testing and LLT varied widely between hospitals (P<0.001). In-hospital lipid testing was positively associated with large teaching hospitals (P=0.029), and neurologist or neurosurgeon (P=0.004); and negatively associated with increasing age (P=0.002), being female (P=0.020), a previous medical history of atrial fibrillation (P=0.002), nonambulatory status (P=0.005), and poor prognosis (P<0.001). LLT at discharge was positively associated with a previous medical history of dyslipidemia (P<0.001), lipid testing (P=0.004), and elevated low-density lipoprotein levels (P<0.001). Among subjects who were not on LLT at admission but who had Adult Treatment Panel III-based indications for use of LLT, only 31.2% (20.5% to 44.5%) received LLT at discharge. CONCLUSIONS: Many hospitalized acute IS and TIA patients with indications for LLT are untreated at discharge. Efforts to close treatment gaps in lipid evaluation and treatment require sustained quality improvement efforts and should pay particular attention to high-risk patients.

We describe a new scleral fixation technique for posterior chamber intraocular lens (IOL) implantation in eyes with partial or total loss of the posterior capsule or zonule support. This technique uses a scleral incision that can be completed in less time than a conventional scleral flap and prevents unnecessary trauma to the eye. A double-thread, 10-0 polypropylene suture loop is introduced once through a scleral layer pathway inside the eye. The free ends of the polypropylene suture are buried between the 2 edges of the scleral incision. This technique was used in 15 eyes, with a follow-up of 6 to 30 months. Complications included iris capture, irregular pupil, hyphema, vitreous hemorrhage, choroidal hemorrhage, localized peripheral anterior synechias, and retinal detachment. The mean postoperative visual acuity was 20/40 at the last follow-up. This modified technique is an easy and effective way to achieve scleral fixation of the IOL.

Veterans of the Gulf War present various symptoms and maladies. Reports by governmental and private entities have yielded mixed results and have been fraught with criticisms of biased research design. The vast majority of these studies have focused on U.S. veterans, with a much smaller number focusing upon British veterans. Very few have examined Iraqi Gulf War veterans. Our study involves administering a health issues questionnaire to a sample of Iraqi Gulf War veteran refugees in the U.S. Results indicate relationships between Post-Traumatic Stress Disorder (PTSD) scores and health outcome measures of chronic fatigue, fibromyalgia, functional status, quality of life, and health care utilization in terms of frequency and level of intensity. Implications for further inquiry are presented.

BACKGROUND: Intracoronary imaging (ICI) during percutaneous coronary intervention (PCI) improves outcomes, yet hospital- and physician-level variabilities in ICI and its impact on ICI use in contemporary PCI remain unknown. This study was performed to evaluate hospital- and physician-level use of ICI to optimize PCI. METHODS: Using data from a large statewide registry, patients undergoing PCI between July 2019 and March 2021 were studied. The primary measure of interest was ICI (intravascular ultrasound or optical coherence tomography) optimization during PCI. A fitted hierarchical Bayesian model identified variables independently associated with ICI optimization. The performing hospital and physician were included as random effects in the model. RESULTS: Among 48 872 PCIs, ICI optimization was performed in 8094 (16.6%). Median [interquartile range] hospital- and physician-level frequencies of ICI were 8.8% [3.1%, 16.0%] and 6.1% [1.1%, 25.0%], respectively. Bayesian modeling identified left main PCI (adjusted odds ratio [aOR], 4.41; 95% credible interval [3.82, 5.10]), proximal left anterior descending artery PCI (aOR, 2.28 [2.00, 2.59]), PCI for in-stent restenosis (aOR, 1.55 [1.40, 1.72]), and surgical consult prior to PCI (aOR, 1.21 [1.07, 1.37]) as independent predictors of ICI optimization. The hospital-level median odds ratio, an estimate of the contribution of inter-hospital variability in odds of ICI use, was 3.48 (2.64, 5.04). Physician-level median odds ratio was 3.81 (3.33, 4.45). CONCLUSIONS: Substantial hospital- and physician-level variation in ICI was observed. Except for performance of left main PCI, the hospital and physician performing the PCI were more strongly associated with ICI optimization than any patient or procedural factors.

BACKGROUND: Foot and ankle injuries are common in sports, particularly in cleated athletes. Traditionally, the athletic shoe has not been regarded as a piece of protective equipment but rather as a part of the uniform, with a primary focus on performance and subjective feedback measures of comfort. Changes in turf and shoe design have poorly understood implications on the health and safety of players. EVIDENCE ACQUISITION: A literature search of the MEDLINE and PubMed databases was conducted. Keywords included athletic shoewear, cleated shoe, football shoes, and shoewear, and search parameters were between the years 2000 and 2016. STUDY DESIGN: Clinical review. LEVEL OF EVIDENCE: Level 5. RESULTS: The athletic shoe is an important piece of protective sports equipment. There are several important structural considerations of shoe design, including biomechanical compliance, cleat and turf interaction, and shoe sizing/fit, that affect the way an athlete engages with the playing surface and carry important potential implications regarding player safety if not understood and addressed. CONCLUSION: Athletic footwear should be considered an integral piece of protective equipment rather than simply an extension of the uniform apparel. More research is needed to define optimal shoe sizing, the effect that design has on mechanical load, and how cleat properties, including pattern and structure, interact with the variety of playing surfaces.