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ABSTRACT Background Left atrial appendage occlusion (LAAO) has emerged as a non‐pharmacological alternative to oral anticoagulation (OAC) for stroke prevention in patients with atrial fibrillation (AF). Following the publication of recent CHAMPION‐AF and CLOSURE‐AF trials, an updated synthesis of evidence is warranted to clarify the long‐term comparative efficacy and safety of LAAO versus OAC in patients with AF. Methods We conducted a systematic review and meta‐analysis of randomized controlled trials (RCTs) comparing LAAO with OAC in adults with AF. A comprehensive search of major databases was performed from inception to April 2026. The primary efficacy outcomes were major adverse cardiovascular events (MACE) and stroke. The primary safety outcome was non–procedure‐related bleeding. Random‐effects models were used to calculate pooled risk ratios (RRs) with 95% confidence intervals (CIs). Results Six RCTs including 7,004 patients (3,681 LAAO; 3,323 OAC) were analyzed. No statistically significant difference was observed for MACE (7.5% vs 6.9%; RR 1.03, 95% CI 0.79‐1.34) or stroke (3.7% vs 3.2%; RR 1.07, 95% CI 0.80‐1.43). LAAO was associated with a significantly lower risk of non‐procedure‐related bleeding (9.8% vs 16.7%; RR 0.63, 95% CI 0.52‐0.77), corresponding to an absolute risk reduction of 6.9% and an approximate number needed to treat of 15 based on crude pooled event rates over the observed trial follow‐up. Trial sequential analysis indicated that the accumulated evidence for MACE and stroke remained inconclusive. Comparator‐type subgroup analyses showed no significant interaction for MACE ( p = 0.67) or stroke ( p = 0.81) between contemporary predominantly‐DOAC and VKA comparator trials. Conclusions LAAO was associated with lower non‐procedure‐related bleeding, while no statistically significant differences were observed for MACE or stroke. The available efficacy evidence remains inconclusive regarding equivalence or non‐inferiority, and larger trials are needed. These findings support individualized consideration of LAAO when the long‐term bleeding burden of anticoagulation is clinically important.

Background: Monitored anesthesia care (MAC) combined with regional anesthetic techniques is commonly used for open reduction and internal fixation (ORIF) of unstable ankle fractures. When compared to general anesthesia (GA), MAC with regional anesthesia has been associated with reduced systemic adverse effects and shorter recovery times, although regional anesthesia carries additional costs and potential complications of its own. A new technique involving the infiltration of high-volume, low-concentration (VL) local anesthetic was therefore developed. When used in conjunction with MAC, we refer to this technique as MAC-VL. This study evaluates outcomes and recovery metrics following outpatient ankle ORIF performed under GA vs MAC-VL without regional anesthesia. Methods: An IRB-approved retrospective cohort study was conducted including 159 adults who underwent outpatient ankle ORIF between February 1, 2023, and January 31, 2026. Patients were identified using standardized diagnostic and procedural codes and grouped according to anesthesia type. All patients received a standardized injection of local anesthetic around the proposed operative sites before the procedure; anesthesia type was MAC (n = 48) or GA (n = 111). The primary outcome was time to discharge, defined as the interval from incision closed to hospital discharge. Secondary outcomes were considered exploratory and included tourniquet, operative, anesthesia time, time in room, Post Anesthesia Care Unit length of stay, conversion from MAC to GA, reported postoperative nausea and vomiting, admissions, and postoperative emergency department visits. Results: Among 160 procedures for which no significant difference in case mix could be detected with the numbers available, MAC-VL was associated with a significantly shorter time to discharge—reducing discharge time by 55.2 minutes ( P < .001) following adjustment for demographic, clinical, and operative covariates—and shortened total anesthesia and operating room time compared with GA. With the numbers available, no significant difference was detected for the remaining secondary outcomes. Conclusion: The MAC-VL protocol was associated with shorter operating room and recovery times and may improve health care resource use. Level of Evidence: Level III, retrospective cohort study.

Objective To identify barriers and facilitators to changing provider's current approaches to evaluation and treatment decision-making for velopharyngeal insufficiency (VPI). Design Cross-sectional qualitative study. Setting Medium and large multidisciplinary cleft teams in the USA and Canada engaged in clinical research. Participants Twenty-eight surgeons and 16 speech-language pathologists from 12 cleft teams. Interventions Semi-structured interviews were conducted exploring perceived barriers and facilitators to changing VPI evaluation and treatment decision-making. Interviews were analyzed using a thematic approach guided by the Consolidated Framework for Implementation Research. Results Providers indicated that adoption of new approaches to VPI evaluation and decision-making would require evidence demonstrating improved speech outcomes or reduced risk of obstructive sleep apnea. Characteristics of persuasive evidence included prospective study design, comparable patient groups, standardized speech evaluations, and long-term follow-up. Providers favored applying new approaches to complex cases or defined subgroups, rather than broad adoption. Providers raised concerns about additional preoperative testing, perceiving it could increase treatment burden. When reflecting on prior changes in care delivery, providers indicated they started by discussing the potential change informally with team members to share information, gather input, and build consensus; in larger teams, discussions also occurred in formal meetings or through administrative hierarchies. Implementation decisions were consensus-based, although the pace of implementation varied among providers. Conclusions Providers have processes for implementing changes in their VPI evaluation and treatment decision-making, and criteria by which they make the decision to implement. These findings can inform the design of implementation strategies to accelerate clinical uptake of research findings.

BACKGROUND: Anemia affects more than two billion people worldwide and is common among surgical patients. Despite growing recognition of the risks associated with preoperative anemia, we have limited understanding of the epidemiology of anemia development and recovery. METHODS: This is an observational cohort study of adults undergoing surgery at a large tertiary care medical center from August 2012 to July 2023. Hemoglobin concentrations were obtained preoperatively, during postoperative hospitalization, and through 12 months after surgery. Anemia was defined primarily using World Health Organization criteria (hemoglobin <12 g/dL in women, <13 g/dL in men) and secondarily with a gender-neutral threshold of <13 g/dL. Descriptive analyses summarize preoperative anemia prevalence, postoperative anemia prevalence and incidence, and post-hospitalization anemia recovery across demographic, clinical, and surgical features. RESULTS: 281,217 patients undergoing 423,066 procedures (51.9% among women) were included. Among those with available preoperative hemoglobin assessments (n = 308,959), 28.9% had anemia, with similar prevalence in men (29.5%) and women (28.4%) using World Health Organization (WHO) definitions, but with prevalence increasing to 51.0% in women when using the gender-neutral anemia definition. Preoperative anemia was most common in Black patients (44.0%) and in those ≥75 years (39.6%). Surgical subspecialties showed wide variation in preoperative anemia prevalence, ranging from 18.6% in spine surgery to 45.8% in vascular surgery. Among previously nonanemic patients admitted to the hospital postoperatively, 76.9% developed new postoperative anemia, with the highest incidence in cardiac surgery (97.5%). Women experienced more severe postoperative anemia than men. Overall, 81.1% of patients were anemic at hospital discharge. Recovery was gradual and incomplete: among those discharged with mild, moderate, or severe anemia, 28.5%, 51.9%, and 66.3%, respectively, remained anemic at 12 months. Among patients who were nonanemic preoperatively but developed new postoperative anemia, 29.3% remained anemic at 12 months. CONCLUSIONS: Preoperative and postoperative anemia are highly prevalent, and anemia frequently persists for months after hospitalization. Older adults, women, and Black patients bear a disproportionate burden. Despite this, anemia evaluations and treatments remain underutilized. These findings highlight substantial opportunities for patient blood management (PBM) programs to improve perioperative anemia detection, optimization, and post-discharge management.

Systematic reviews of randomized controlled trials (RCTs) support evidence-based clinical advancement. Clinical trial reporting guidelines, including CONSORT, establish common data elements that support systematic synthesis of published trial outcomes. However, the rapid rise of digital health technologies presents new challenges for reporting guidelines, and substantial real-world reporting heterogeneity has been observed. Therefore, machine-assisted evaluation of reporting adherence offers a pathway for more agile information management to accommodate the diverse and disruptive nature of digital health technology-enabled RCTs. Here, we propose an accelerated retrieval-to-abstraction literature synthesis framework to conduct article screening, text and table data preprocessing, and full-text review using an unmodified pretrained large language model. We apply this methodology in two digital health technology-enabled RCT case studies evaluating adherence to technology and digital health equity guideline reporting items. Large language model performance was on par with inter-annotator agreement F1 scores (≥0.9) in both screening and information-extraction tasks. These findings support the scalability and rigor of accelerated evidence synthesis and demonstrate the importance of common reporting elements across digital health technology-enabled RCTs.

Background: The limb symmetry index (LSI) is a measure comparing strength and functional movement between the surgical and nonsurgical limbs, used after anterior cruciate ligament reconstruction (ACLR) to guide rehabilitation and assess return-to-sport readiness. With increasing use of the quadriceps tendon autograft (QT-ACLR), limited data exist on whether the LSI score correlates with patient-reported outcome measures (PROMs). Hypothesis/Purpose: To evaluate the predictive value of postoperative strength and functional LSI tests at 3, 6, and 9 months for short-term PROMs, determine Patient Acceptable Symptom State (PASS) thresholds, and assess differences based on PASS achievement. It was hypothesized that quadriceps strength LSI score would more strongly predict 2-year PROMs than hamstring strength LSI score, and that higher 9-month isokinetic quadriceps LSI scores would be associated with higher International Knee Documentation Committee (IKDC) and Lysholm scores. Study Design: Case series; Level of evidence, 4. Methods: Patients undergoing primary QT-ACLR from 2021 to 2024 with LSI testing during rehabilitation (isometric and isokinetic lower extremity strength, Y-Balance, hop testing) and no revision or additional knee surgery were included. The LSI score was assessed at 3, 6, and 9 months, and PROMs, including Lysholm and IKDC scores, were collected at a mean follow-up of 2.0 ± 0.7 years. Multivariable linear regression was used to evaluate associations between LSI measures and PROMs after adjusting for age, sex, and body mass index (BMI). Receiver operating characteristic analysis was used to determine PASS thresholds. Results: A total of 100 knees in 100 patients (mean age, 25.3 ± 11.2 years; BMI, 25.9 ± 6.5 kg/m 2 ; 52% male) were included. Quadriceps and hamstring strength and functional performance progressively improved from 3 to 9 months, with the LSI score reaching 77% to 81% for quadriceps strength and 98% to 100% for hamstring strength by 9 months postoperatively. At a mean follow-up of 2.0 ± 0.7 years, the mean satisfaction score was 8.4 of 10, the Lysholm score was 90.7, and the IKDC score was 77.8. Linear regression, adjusted for age, sex, and BMI, demonstrated that 3-month isometric quadriceps LSI score had a strong effect on IKDC score, explaining substantial variance (β = 3.9; adjusted R 2 [Adj R 2 ] = 0.36; P < .03); 6-month isokinetic quadriceps and hamstrings showed moderate but significant effects (β = 2.9-3.7; Adj R 2 = 0.13-0.17; P < .05) on IKDC score; and 9-month fast quadriceps had a strong effect explaining substantial variance in Lysholm and IKDC scores (β = 3.9-4.7; Adj R 2 = 0.34-0.35; P ≤ .003). Lysholm and IKDC scores correlated with satisfaction and accurately discriminated PASS thresholds (area under the curve, 0.927-0.937; P < .001). Patients achieving the IKDC PASS demonstrated higher LSI scores across time points and all PROMs. Conclusion: After QT-ACLR, strength-associated LSIs were independently associated with PROMs at a mean 2-year follow-up, after adjusting for age, sex, and BMI. Early isometric quadriceps strength at 3 months predicted higher 2-year IKDC scores, with PASS achievers generally attaining a 60% to 70% LSI score by 3 months. Isokinetic quadriceps strength at 9 months predicted both IKDC and Lysholm scores. These findings highlight the importance of early quadriceps strength recovery and the value of LSI measures in predicting PROMs and informing early rehabilitation.

Background: Iliopsoas impingement (IPI) is a known cause of persistent anterior hip pain following total hip arthroplasty (THA). Management of IPI has often relied on an 8-mm anterior acetabular overhang threshold to guide operative treatment, favoring acetabular revision for greater overhang and iliopsoas tenotomy for lesser overhang. These thresholds were initially established on the basis of the outcomes of open tenotomy, and now, with an improved understanding of IPI and the advent of arthroscopic iliopsoas fractional lengthening (IPFL), a review of the 8-mm threshold is warranted. Methods: A retrospective review was performed to identify patients who underwent arthroscopic IPFL following primary THA between 2017 and 2024, with a minimum follow-up of 1 year. Acetabular overhang was measured for all patients using cross-table lateral radiographs, and patients were stratified into <8-mm and ≥8-mm cohorts. Patient-reported outcome measures, reoperations, revisions, and complications were collected and analyzed on the basis of both the classic 8-mm threshold and continuous statistical methods. Results: We evaluated 86 hips undergoing IPFL. There were 83 patients (30 men and 53 women), with a mean age of 63.0 ± 11.2 years; with regard to race, 80 patients were White, 1 patient was Black or African American, and 2 patients listed other race or chose not to disclose. The acetabular overhang was <8 mm for 67 hips and ≥8 mm for 19 hips. The mean follow-up was 2.5 ± 1.6 years (range, 1 to 7.5 years). When comparing patients with <8-mm and ≥8-mm acetabular overhang, we observed no significant differences (p > 0.06) in the preoperative and postoperative visual analog scale (VAS) pain scores, modified Harris hip score, Single Assessment Numeric Evaluation (SANE) score, Tegner activity level, subjective groin pain improvement, subjective hip flexion strength improvement, and overall satisfaction. Reoperation (2.9% compared with 10.5%; p = 0.210) and acetabular revision rates (1.5% compared with 5%; p = 0.387) were not significantly different between the <8-mm and ≥8-mm overhang groups. Conclusions: Arthroscopic IPFL provided satisfactory outcomes for patients with IPI, independent of the magnitude of acetabular overhang. IPFL should be considered for first-line surgical management of IPI refractory to nonoperative management, even in the setting of substantial acetabular overhang, given positive outcomes and low rates of subsequent acetabular revision. Level of Evidence: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Background Native American (NA) patients experience persistent inequities in advance care planning (ACP) and often present to tertiary centers with critical illness; culturally respectful serious-illness communication is therefore essential in emergency and intensive care settings. Intervention We developed and implemented a nursing-led, multidisciplinary educational initiative at a large academic medical center serving patients from >50 tribal nations. Informed by a literature review, local practice needs, and expert input from a Native American Patient Experience Ambassador, we created (1) an “Honoring Your Choices” (HYC) communication card with culturally sensitive prompts for serious illness conversations and (2) a quick reference guide (QRG) outlining key cultural considerations and unit-specific resources. Tools were disseminated to seven intensive care units and the emergency department through nurse leader engagement, unit rounding, and staff education, and the initiative was presented at departmental Grand Rounds/didactics with pre/post surveys to assess impact. Results Twenty-seven pre-session and twenty-four post-session surveys were collected from clinicians and trainees. Prior to the session, >80% of respondents reported being not or only slightly confident discussing end-of-life issues with NA patients/families; post-session surveys demonstrated increased self-reported confidence in recognizing when cultural beliefs may influence care and in conducting end-of-life discussions. Conclusions This initiative demonstrates how culturally congruent approaches to serious illness conversations may support more meaningful engagement with NA patients and families. Our experience suggests that developing and evaluating a brief, point-of-care communication tool like Honoring Your Choices may be accomplished with existing interdisciplinary partnerships, offering a practical model that other institutions can readily mirror.