Time to add a fifth pillar to bedside physical examination: Inspection, palpation, percussion, auscultation, and insonation. Traditionally, the four pillars of bedside physical examination are inspection, palpation, percussion, and auscultation. In this paper, Drs. Narula, Chandrashekhar and Braunwald propose adding a fifth element—bedside ultrasound (or insonation).   This is timely for several reasons, including that current physical examination skills in new trainees are often suboptimal and efforts to improve examination skills during medical training have not been particularly successful. Also, point-of-care handheld ultrasound systems are now available that make bedside insonation imminently feasible. The newest devices are handheld, in some cases wireless, compatible with smartphone technologies, and, in one case, costing less than $2000. MORE

The optimal timing of mitral valve surgery in asymptomatic patients with primary mitral regurgitation (MR) remains controversial. Zilberszac et al sought to assess the 20-year outcome of an active surveillance strategy in a large population of patients with severe primary MR managed in a dedicated heart valve clinic. A total of 280 patients (mean age at baseline, 58 years; 31% female) with severe asymptomatic primary MR (prolapse of flail leaflet) were assessed between 1997 and 2015 and enrolled in a long-term follow-up program. All were prospectively followed every 6 months with clinical and echocardiographic examinations until surgical criteria were reached, at which time they were immediately referred to surgery. The researchers measured event-free survival and overall survival as compared with an age- and gender-matched general population. MORE

The following two papers show the gradually increasing genetic knowledge base in ACL science, and medicine generally. The first paper is illustrative of the impressive work being done showing that not all connective tissue is created equal. At the extremes, such as Ehlers Danlos syndrome, this has always been appreciated. But scientists are now able to correlate genetically different collagen with differing injury rates. In this study, different haplotypes of the COL5A1 gene were associated with greater or lesser risk of ACL tears. A study group and control group of soccer players was used. As the authors state, this a non-modifiable risk factor physically. However, one might, for example, counsel an athlete with a high risk haplotype to undertake an ACL prevention program given the greater risk. MORE

Oral anticoagulation (OAC) is superior to dual antiplatelet therapy (DAT) in preventing stroke in patients with atrial fibrillation (AF), but DAT is superior to OAC in preventing stent thrombosis and ischemic events after percutaneous coronary intervention (PCI). MORE