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Aims Periacetabular osteotomy (PAO) is performed in young, opioid-naive patients and is associated with postoperative pain. Optimizing perioperative analgesia while limiting opioid exposure remains a priority. This study evaluated postoperative pain trajectories, hospital length of stay (LOS), and opioid-prescribing patterns associated with an institutional transition from epidural-based to periarticular injection (PAI)-based analgesia after PAO. Secondary aims were to assess the influence of preoperative opioid exposure and compare outcomes between ropivacaine-based and bupivacaine PAI formulations. Methods The study included 724 patients who underwent PAO between January 2010 and December 2022 at a single academic institution, with epidural use replaced by PAI in 2016. Patients were stratified by postoperative analgesia strategy: epidural catheter (n = 333) or PAI (n = 391). Outcomes included daily postoperative pain scores, LOS, discharge opioid prescriptions (morphine milligram equivalents (MMEs)), total opioid exposure, and 30-day refill rates. Statistical comparisons were performed using chi-squared, Fisher’s exact, and Kruskal–Wallis tests. Results Baseline characteristics were similar between groups. Epidural analgesia was associated with lower pain scores during the first 48 hours (last pain postoperative day 0 to 1: mean 2.9 (SD 2.0) vs 4.7 (SD 2.1); p < 0.001), whereas the PAI group had a shorter LOS (mean 2.2 days (SD 1.0) vs 3.4 days (SD 0.9); p < 0.001) and higher pain scores at discharge (mean 4.8 (SD 1.9) vs 4.0 (SD 1.9); p < 0.001). Median discharge opioid prescriptions (313 (IQR 225 to 388) vs 825 (IQR 600 to 1,000) MMEs) and total 30-day opioid exposure (360 (IQR 275 to 575) vs 900 (IQR 638 to 1,100) MMEs) were lower in the PAI group (both p < 0.001), while refill rates were higher (34.0% vs 19.2%; p < 0.001). Within the PAI cohort, ropivacaine-based and bupivacaine injections showed similar pain trajectories and refill rates. Conclusion Epidural analgesia provided superior early postoperative pain control, whereas PAI-based pathways enabled earlier discharge and lower overall opioid prescribing but with higher refill rates. These findings highlight trade-offs in contemporary perioperative pathways and support individualized analgesic strategies after PAO. Cite this article: Bone Jt Open 2026;7(11):1410–1418.

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.

Objective To evaluate the efficacy of cytokine‐directed therapies in VEXAS (vacuoles, E1 enzyme, X‐linked, autoinflammatory somatic) syndrome using previously proposed treatment response criteria. Methods All patients with genetically confirmed VEXAS syndrome who received targeted therapies with JAK inhibitors (JAKi), tumor necrosis factor α inhibitors (TNFαi), or interleukin‐1 (IL‐1) or IL‐6 inhibitors were identified. Clinical and biochemical data were recorded for patients at time of targeted therapy initiation, and at 3‐, 6‐, and 12‐month follow‐up time points. Treatment response was labeled as complete response (CR; normalization of C‐reactive protein [CRP], prednisone <10 mg/day, and resolution of disease activity), partial response (PR; >50% improvement in CRP, >50% prednisone dose reduction, improvement or resolution of disease features), treatment failure (TF; worsening CRP, increasing prednisone, worsening of disease features), or no response (not meeting criteria for CR, PR, or TF). Results Overall, 52 patients received an IL‐1i, IL‐6i, or JAKi therapy. At six‐month follow‐up, 3 of 19 IL‐6i patients experienced CR, 4 of 19 experienced PR, and 7 of 19 experienced TF. 2 of 17 patients receiving JAKi experienced CR, 3 of 17 experienced PR, and 6 of 17 experienced TF. No patients receiving IL‐1i or TNFαi experienced CR, and only 1 of 5 IL‐1i patients experienced PR. Among those still receiving biologic therapy at 12 months, only 1 of 11 receiving IL‐6i and 0 of 7 receiving JAKi experienced CR. Conclusion IL‐6i and JAKi therapies demonstrated limited, unsustained efficacy for management of VEXAS syndrome. IL‐1i and TNFαi therapies were not efficacious. Useful application of previously reported treatment response criteria was demonstrated, but future incorporation of hematologic parameters may be beneficial.

ABSTRACT Background ACS‐NSQIP began capturing operative approach in 2022. With increased adoption of minimally invasive (MIS) techniques for malignancy, a contemporary review of benchmark outcomes for open, laparoscopic and robotic gastrectomy is warranted. Methods We performed a retrospective cohort study of adults in ACS‐NSQIP (2022–2024) undergoing partial or total gastrectomy (CPT 43631‐4 and 43620‐2) for cancer. Outcomes included operative time, length of stay (LOS), unplanned conversion‐to‐open, and 30‐day morbidity, mortality, and readmission. Multivariable logistic regression evaluated patient and operative factors associated with morbidity. Results Among 1,459 patients (median age 66, 60.4% male), 66.8% underwent partial gastrectomy and 33.2% total gastrectomy. Approaches were 61.2% open, 19.5% laparoscopic, and 19.3% robotic. Thirty‐day mortality (1.8%), major complications (18.2%), and readmissions (10.3%) did not differ by approach. Unplanned conversion‐to‐open occurred in 14.0% of MIS. Robotic had longer median operative time of +1.2 and +1.7 h than laparoscopic and open and median −1 and −2 days shorter LOS respectively ( p < 0.001). Hypoalbuminemia (OR 3.10), CKD ≥ 3 (OR 1.75), and anemia (OR 1.48) were independently associated with major complications ( p < 0.05). Conclusion Operative approach influences operative time and LOS but not short‐term morbidity and mortality. The newly available ACS‐NSQIP operative approach variable enables approach‐specific benchmarks for cancer‐related gastrectomy.

Financial toxicity is a significant but often overlooked consequence of cancer for adolescents and young adults (AYAs, 15–39 years old), who face limited savings, unstable employment, and insurance gaps that heighten financial stress. As part of a larger initiative to determine whether our cancer center can use an existing social drivers of health (SDOH) screening process to identify patients who may benefit from targeted supportive interventions, we sought to characterize financial strain, toxicity, and SDOH needs in AYAs treated in our cancer center and compare them to both younger and older cancer patients. This is a cross-sectional observational study at Mayo Clinic of patients with an oncology-related department visit between 8 September 2023–4 June 2024 (N = 81,731) who completed routine institutional electronic screenings for financial strain and SDOH. Survey items assessed financial strain, transportation barriers, and food insecurity; institutional billing data captured financial toxicity (unresolved balances, collection referrals, write-offs). AYAs (n = 5655) were more likely than non-AYAs to report medium/high financial strain, have unpaid debt, or have an unresolved balance, referral to a collection agency, or bad debt write-off, with nearly double the odds of medium/high financial strain compared to patients over 40 (OR 2.02, 95% CI 1.84–2.23, p < 0.001). Within AYAs, ages 26–32 bore the greatest burden: 24.2% in the medium/high-risk category, 9.4% with unresolved billing issues or collections, and 11.6% reporting food insecurity. These findings identify AYAs—particularly those 26–32—as a distinct high-risk group for financial toxicity and health-related social needs, underscoring the need for targeted interventions, tailored financial navigation, and policy efforts to reduce economic barriers to care. Future research should evaluate the effectiveness of these interventions in mitigating financial toxicity, addressing health-related social needs, and improving patient outcomes in this population.

Objectives Long-term symptoms following infection with acute respiratory syndrome coronavirus-2 (SARS-CoV-2), termed post-acute sequelae of SARS-CoV-2 infection (PASC) or Long COVID (LC), persist beyond 90 days and may impact at least 10% of patients with acute infection. The exact cause of LC remains unknown, but several theories include persistent viral particles, immune dysfunction, and autonomic nervous system (ANS) imbalance, particularly involving the vagus nerve. Given the role of the vagus nerve in inflammation regulation, vagal nerve stimulation (VNS) is being explored as a treatment option. The present study aimed to evaluate the feasibility, safety, and exploratory effects of a handheld external transcutaneous cervical non-invasive VNS (tcVNS) on the primary endpoint of Post-COVID Functional Status (PCFS) grade, alongside secondary outcomes such as LC-related fatigue and other symptoms. Methods Participants from our Post COVID Care Clinic were randomized into treatment (tcVNS treatments two minutes, three times a day) and control (no VNS) groups for a study period of 12 weeks. Participants completed validated questionnaires, PET-CT scans, and inflammatory cytokines at baseline and 12 weeks. Results All randomized patients (8 tcVNS, 10 control) completed the 12-week study. Participants randomized to tcVNS were observed to have improvements in PHQ-9, PROMIS-F, and COMPASS-31 when compared to controls, but these differences were not statistically significant. Cortisol and DHEA were also observed to increase less in the tcVNS group when compared to the control group, but these changes were also not statistically significant. Conclusions tcVNS was well tolerated and may be a promising therapeutic approach for LC, a chronic disease with no approved treatments and very low rates of complete recovery.

Prehabilitation with Impella 5.5 offers hemodynamic support while allowing early mobilization, yet its overall effect on post-transplant recovery remains unclear. The aim was to assess recovery during Impella 5.5–supported prehabilitation and determine its association with early post-heart transplant outcomes, including a potential dose–response relationship with ambulatory activity. We conducted a single-center retrospective cohort study of adults bridged to transplant with Impella 5.5 between April 1, 2022 and September 30, 2024. Daily walking distance, recorded by nursing staff, served as the intervention. Primary outcome was postoperative hospital length of stay (LOS); the secondary outcome was time to extubation. Fine–Gray competing-risk models, adjusted for age, Sequential Organ Failure Assessment (SOFA) score, New York Heart Association (NYHA) class, and days of Impella support, assessed associations. Longitudinal recovery trajectories were analyzed with linear mixed-effects models incorporating restricted cubic splines. Among 82 eligible patients, 65 met the inclusion criteria. Patients who walked farther during Impella 5.5 support in the intensive care unit (ICU) had shorter hospital stays and were taken off the ventilator sooner after transplantation. The overall recovery peaked during the first 2–3 weeks of support, with smaller recovery thereafter, indicating that most functional recovery occurred early during prehabilitation.

Abstract Background For many evidence criteria within v3.0 of the ACMG/AMP guidelines, methodologies have been developed to empower their use outside the stipulated evidence strengths. However, no such methodology has been established for case-control data (PS4). With the release of large-scale unselected case-control datasets and expansion of nationally-collected laboratory datasets enriched for pathogenic variant carriers, there is potential to combine datasets across ascertainment contexts in a more quantitative manner using novel likelihood ratio tools. Methods Using our published PS4-LR-Calculator, we calculated a combined log likelihood ratio (PS4-LLR) across five datasets (three unselected, and two enriched), and estimated enrichment of pathogenic variants in clinically-ascertained laboratory data using truncating variant prevalence. Results Data were combined for 10,817 missense variants from 325,345 female breast cancer patients and 671,006 controls of Western European ancestry for five breast cancer susceptibility genes ( BRCA1, BRCA2, PALB2, ATM, CHEK2 ). A combined LLR was produced for 4,690 missense variants; 927 variants received evidence towards pathogenicity (LLR≥ 1), and 3,242 received evidence towards benignity (LLR≤ -1). Conclusion This flexible, variant-level methodology combines nationally-collected ‘enriched’ datasets with unselected case-control cohorts, expanding the available information for case-control analysis, boosting power, enabling exploration of atypical penetrance and empowering variant classification.