To synthesize recent developments in anterior cruciate ligament reconstruction (ACLR), highlighting emerging evidence, evolving surgical strategies, and persistent controversies in risk stratification, graft selection, surgical planning and rehabilitation. A narrative review of the recent literature (2023-2026) was conducted, incorporating randomized controlled trials, systematic reviews, large registry analyses and emerging studies. The review focused on evolving concepts in graft selection, imaging-guided surgical planning, biomechanical risk factors, neuromuscular recovery and long-term outcomes following ACL reconstruction. Quadriceps tendon autografts have gained prominence for their robust dimensions and low donor-site morbidity, with bone-block variants potentially enhancing rotational stability. Imaging innovations-3D mapping, navigation and individualized morphometrics-improve tunnel precision. New studies reinforce posterior tibial slope, notch shape and hyperextension as critical anatomical risk factors. Neuromuscular training techniques such as VR-based rehabilitation, blood flow restriction, and individualized strength timelines improve functional symmetry and readiness. Registry data show rising ACLR rates, especially among young females, and link failure to younger age, high activity, delayed surgery and septic arthritis. PROMs correlate poorly with objective performance, underscoring the need for integrated assessment. Long-term outcomes remain favourable across graft types, with no consistent differences in osteoarthritis progression. ACLR is transitioning toward a precision-based, individualized model. This paradigm shift integrates anatomical risk profiling, tailored graft selection, and multimodal rehabilitation to optimize both biological and functional outcomes. Yet, unresolved questions, around pediatric predictors, repair techniques, and real-world adherence, highlight the need for ongoing refinement. The field is evolving from reconstruction toward comprehensive restoration, grounded in anatomy, technology and behavioural science. Level V, narrative review.
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Recent reports indicate that approximately half of the head impacts and one third of the concussions in American football occur due to contact with the helmet's facemask. Despite this, helmet innovations have primarily focused on improving attenuation of impacts to the helmet shell. During facemask impacts, the chinstrap goes into tension and materials in the chin cup are compressed. Various chinstraps are available to equip to helmets and the present study sought to conduct the first known evaluation of the influence of the chinstrap on facemask impact severity. Fourteen different chinstraps were affixed to an identical American football helmet which was subjected to laboratory impact testing. Chin cup liner thickness and lengths of the top and bottom straps were measured for each chinstrap. A linear impactor delivered impacts at 3.0 and 7.4 m/s at a central facemask impact location while the helmet was worn by a medium NOCSAE headform. Head kinematics were recorded and used to compute the Head Acceleration Response Metric (HARM), a brain injury risk metric derived from linear and rotational head kinematics. One-way ANOVAs revealed a statistically significant effect of chinstrap model on HARM at both impact velocities (p < 0.0001). Differences in HARM between chinstraps were as great as 35.4% at 3.0 m/s and 31.4% at 7.4 m/s. There was a statistically significant association between HARM and chin cup liner thickness at 3.0 m/s (p = 0.0002), indicating thicker chin cup liners resulted in lower HARM (R2 = 0.706), but this trend was not observed at 7.4 m/s (p = 0.14, R2 = 0.450). Top strap length was not significantly associated with HARM at 3.0 m/s (p = 0.689) or 7.4 m/s (p = 0.541). There was a statistically significant association between HARM and bottom strap length at 3.0 m/s (p = 0.004, R2 = 0.523), but this trend was not observed at 7.4 m/s (p = 0.799). Overall, we report that the chinstrap can significantly influence the severity of facemask impacts in American football helmets across multiple impact velocities. Increasing chinstrap liner thicknesses and strap lengths may yield reductions in kinematics-based injury risk metrics at some impact velocities. Further investigation of the chinstrap system is warranted to inform future chinstrap design toward improved impact attenuation.
Minimally invasive anatomic liver resection (AR) is technically demanding, and the efficacy of robotic surgery in AR remains unestablished. This systematic review aims through a meta-analysis to compare surgical outcomes between robotic (RAR) and conventional laparoscopic (LAR) AR. A systematic literature search of relevant studies published between 2001 and 2024 in PubMed/MEDLINE, Embase and Cochrane Library was carried out, and 15 studies were selected. Meta-analysis was performed to compare perioperative outcomes between RAR and LAR. A total of 4171 patients comprising 2042 RAR and 2129 LAR patients who underwent major hepatectomy or liver parenchyma-sparing AR (PSAR) were included. All included studies were retrospective comparative studies, including eight using propensity score-matched analysis. Meta-analysis demonstrated that as primary outcomes, the 30-day and 90-day mortalities and postoperative overall morbidity were comparable between RAR and LAR, while RAR had significantly less morbidity≥Clavien-Dindo grade II and a lower rate of open conversion. As secondary outcomes, compared to LAR, RAR showed significantly less blood loss and shorter postoperative hospital stay, while RAR had a higher rate of postoperative 30-day readmission. Operative time, blood transfusion, Pringle maneuver, R0 resection, and reoperation were comparable. Subgroup meta-analyses showed a lower rate of blood transfusion in robotic PSAR and a lower rate of open conversion in RAR in the right cranial regions. This large-scale meta-analysis of minimally invasive AR suggests that RAR can confer comparable or partly better perioperative outcomes as compared to LAR, indicating potential advantages of the robotic approach to AR.
While the United States of America (USA) faces a substantial substance use disorder (SUD) burden on a global scale, relatively little is known about the current trends and future trajectories at both national and state levels. Using the Global Burden of Disease Study 2023, we examined estimates of prevalence and disability-adjusted life years (DALYs) for SUDs in the USA, including alcohol use disorders (AUDs) and drug use disorders (DUDs), across all 50 states and Washington, DC, from 1990 to 2023 and forecasted trends to 2050. In 2023, the USA had the highest age-standardized prevalence of SUDs across the globe. Overall, age-standardized SUD prevalence increased from 4,664.6 (95% uncertainty interval, 4,076.4-5,333.3) estimated rates per 100,000 people in 1990 to 6,430.1 (5,871.7-7,056.3) per 100,000 people in 2023, representing an increase of 37.9%. At the state level in 2023, broader geographical variations were observed in terms of estimated age-standardized DALYs for SUDs. At both the national and state levels, the age-standardized prevalence and burden of DUDs have outpaced and surpassed the increase in AUDs over time. By 2050, if existing trends continue, the age-standardized prevalence of SUDs is projected to rise to 8,956.0 (7,478.8-10,118.4) per 100,000 people, driven primarily by increasing age-standardized prevalence of DUDs, while age-standardized prevalence of AUDs is predicted to increase slightly. These findings suggest that current interventions have been insufficient to curb the SUD crisis. Without urgent, evidence-based reforms, the SUD burden will continue to increase and deepen health disparities across the USA. This work was funded by the Gates Foundation.
To assess radiographic progression in patients with early rheumatoid arthritis (RA) and poor prognostic factors treated with certolizumab pegol (CZP)+methotrexate (MTX) versus placebo (PBO)+MTX, stratified by rheumatoid factor (RF) level. In a pooled, post-hoc analysis of phase 3 randomized trials (C-EARLY [NCT01519791] and C-OPERA [NCT01451203], patients were stratified by baseline RF level (low: <200 IU/mL; high: ≥200IU/mL). Change from baseline (Δ) in modified Total Sharp Score (mTSS) and components, predicted risk of RP, and disease activity are reported up to Week (Wk)52. Eight hundred and thirteen CZP+MTX-randomized (low RF: n=571; high RF: n=242) and 367 PBO+MTX-randomized (low RF: n=242; high RF: n=125) patients were included. Baseline characteristics were similar between treatments; however, patients with high RF had more severe disease. The proportion of patients with clinically meaningful radiographic worsening (ΔmTSS >5) at Wk24 was more comparable between patients with high and low RF levels randomized to CZP+MTX (low RF: 1.0% vs high RF: 0.0%) and was numerically lower than with PBO+MTX (2.8% vs 6.5%) and this pattern was maintained through Wk52. Clinical outcomes were generally favorable with PBO+MTX, but better with CZP+MTX. In MTX-naïve patients with early RA, radiographic progression was more similar between CZP+MTX-treated patients with high and low RF levels, and consistently numerically lower, than PBO+MTX-treated patients. Irrespective of RF level, CZP+MTX better attenuated than MTX alone and was associated with more favorable clinical outcomes. Our findings suggest that RF level does not adversely influence radiographic response to CZP+MTX.
Despite calls to publish negative studies in prominent medical journals, greater submission and acceptance of positive results remains an issue. We aimed to quantify the degree to which high-impact general medical journals publish negative study results. We searched MEDLINE/PubMed for all randomized controlled trials published in five high-impact general medicine journals: Annals of Internal Medicine, the British Medical Journal (BMJ), the Journal of the American Medical Association (JAMA), the Lancet, and the New England Journal of Medicine (NEJM). Our search spanned a 10-year period from 2014 to 2023, which included data from before and after the emergence of the COVID-19 global pandemic. We performed single-author data extraction via abstract review to determine study positivity, defined as statistical significance for the primary outcome, flagging abstracts for secondary review if positivity was not clear. Two authors reviewed all flagged abstracts. We calculated the proportion of negative studies (i.e., not meeting statistical significance for the primary outcome) overall, by journal, and by publication year. We used logistic regression to model the odds of a study reporting a negative result by journal and year. Our search yielded 3722 individual citations, with screening resulting in 3600 randomized controlled trials for review, with 31% of studies reporting negative results. The proportion of negative studies varied, ranging from 22% in the Lancet to 51% in BMJ and JAMA. The proportion of negative studies remained consistent over time. High-impact general medical journals vary widely in the percentage of negative studies that they publish but did not change over time, even during and after a global pandemic. Further study is needed to determine factors influencing this phenomenon and what can be done to minimize publication bias.
Glucagon-like peptide-1 receptor agonists (GLP-1RAs) have reshaped the clinical approach to managing obesity and type 2 diabetes. As approved indications have expanded, use of GLP-1RAs has increased rapidly in the United States. Although randomized trials demonstrate strong efficacy, many questions remain about their optimal use in clinical practice. Real-world data (RWD) from electronic health records, registries, insurance claims, and other sources offer a promising avenue to address these questions. However, concerns about data quality, selection bias, and incomplete ascertainment of medication use and outcomes pose significant challenges to the validity of the resulting evidence. In May 2025, the National Institute of Diabetes and Digestive and Kidney Diseases convened experts from regulatory agencies, payer organizations, and academia to explore these challenges. This second of 2 synopsis articles on the workshop summarizes the discussion around the strengths and limitations of various RWD sources and methodological approaches to strengthen causal inference and generalizability. Presenters highlighted pragmatic clinical trials and target trial emulation as strategies to generate stronger real-world evidence (RWE) that is relevant to both clinical practice and policy. The workshop underscored that careful attention to study design, data limitations, and analytic approach is essential to yield RWE that informs clinicians, patients, payers, and policymakers.
Despite improvements in surgical techniques and perioperative management, the incidence of postoperative surgical site infection after pancreatoduodenectomy remains high. This study aim to assess whether broad-spectrum antibiotic prophylaxis can reduce complications after pancreatoduodenectomy compared with standard care antibiotics. Data of patients who underwent pancreatoduodenectomy between July 2010 and March 2022 were extracted from a nationwide Japanese inpatient database. First- and second-generation cephalosporins were designated as narrow-spectrum, and third- and fourth-generation cephalosporins and piperacillin-tazobactam as broad-spectrum antibiotics. Patients who received either narrow- or broad-spectrum antibiotics on the day of surgery were included in the analysis. Using propensity-score stabilized inverse probability of treatment weighting, the postoperative complications were compared between patients who received antimicrobial prophylaxis with narrow-spectrum antibiotics versus broad-spectrum antibiotics. From among 45 099 eligible patients, 36 742 (81.5%) and 8357 (18.5%) patients received narrow- and broad-spectrum antibiotics, respectively. After stabilized inverse probability of treatment weighting, the use of broad-spectrum antibiotics bore a significant association with the reduction in intra-abdominal infections [risk difference (RD), -7.4; 95% confidence interval (CI), -8.7 to -6.0], postoperative pancreatic fistula (RD, -3.0; 95% CI, -4.0 to -1.9), post-pancreatectomy hemorrhage (RD, -1.5; 95% CI, -1.9 to -1.1). The use of broad-spectrum antibiotics was also associated with a shorter postoperative length of hospital stay and lower total hospitalization costs. The proportion of Clostridioides difficile infection did not differ between the groups. The administration of broad-spectrum antibiotics as antimicrobial prophylaxis was associated with better in-hospital postoperative outcomes compared with narrow-spectrum in patients undergoing pancreatoduodenectomy.
Feeding enterostomy is commonly created during minimally invasive esophagectomy (MIE); however, its short-term impact remains unclear. We analyzed 19 054 patients who underwent MIE for esophageal or esophagogastric junction cancer during 2019-2022. Inverse probability of treatment weighting was applied to balance baseline characteristics, and G-computation was used to estimate adjusted risks and means and their differences. A secondary analysis was performed to compare gastrostomy and jejunostomy in retrosternal cases. Of 19 054 patients, 4599 (24.1%) received a feeding enterostomy. After adjustment, the primary outcome, postoperative bowel obstruction, did not differ significantly between enterostomy group and no-enterostomy group (+0.2%, p = 0.132). The enterostomy group demonstrated higher rates of reoperation (+2.5%, p < 0.001) and respiratory complications, including pneumonia (+2.5%, p < 0.001) and prolonged ventilation (+0.9%, p = 0.012), than the no-enterostomy group. Conversely, delayed gastric emptying (-0.9%, p < 0.001) and deep vein thrombosis (-0.4%, p = 0.028) occurred less frequently. Among 2723 patients who underwent retrosternal reconstruction with feeding enterostomy, jejunostomy was associated with a shorter operative time (-11.2 min, p = 0.025), whereas gastrostomy was associated with a 2.3-day shorter hospital stay than jejunostomy (p = 0.022). Bowel-related events were rare, and adjusted comparisons for these outcomes were not performed. Feeding enterostomy during MIE may confer benefits (e.g., reduced delayed gastric emptying and deep vein thrombosis) but is also associated with increased postoperative complications. Routine or uniform placement of a feeding enterostomy should be avoided, and gastrostomy may be preferable in retrosternal reconstruction.
Glucagon-like peptide-1 receptor agonists (GLP-1RAs) have transformed obesity and diabetes management, with rapidly expanding indications and use among U.S. adults. Despite their promise, key questions remain about optimal treatment pathways, long-term safety, effectiveness across diverse populations, adherence, and economic impact. Real-world evidence (RWE) derived from electronic health records, claims, and other data sources could address these gaps, but unique challenges complicate its use, such as inconsistent insurance coverage, high discontinuation rates, medication shortages, compounded formulations, and off-label prescribing. To explore these issues, the National Institute of Diabetes and Digestive and Kidney Diseases convened a workshop in May 2025 with experts from regulatory agencies, guideline committees, payers, and academia. Discussions focused on identifying knowledge gaps in GLP-1RA use, evaluating how RWE informs practice, assessing limitations of real-world data, and strategies to reduce bias in RWE. Presentations emphasized RWE's potential to complement randomized trials by capturing rare adverse events, long-term outcomes, and effectiveness in routine care. However, persistent challenges include data reliability, confounding, and incomplete capture of medication use and outcomes, particularly in pediatric and underserved populations. Coverage decisions remain heterogeneous across Medicare, Medicaid, and private payers and across time, underscoring the need for rigorous cost-benefit analyses. The workshop concluded that robust RWE is essential for developing value-based coverage policies and optimizing GLP-1RA use. Continued investment in high-quality data infrastructure and analytic methods will be critical to inform regulatory, clinical, and economic decisions as utilization expands.
This study aimed to examine characteristics of manipulation performed by experienced surgeons in robotic surgery by analyzing log data obtained from the Japanese surgical robot hinotori. Twelve gastrointestinal surgeons performed four tasks (transportation, dissection, single suturing, and continuous suturing), four times each. In total, 24 trials performed by six experienced surgeons were classified as the experienced (E) group, and 24 trials conducted by six less-experienced surgeons were classified as the less-experienced (L) group. Forceps log data were collected using the Medicaroid Intelligent Network, a hinotori network support system. Data on parameters such as instrument travel distance, velocity, acceleration, jerk, normalized mean squared jerk, wrist articulation counts, and scope manipulation characteristics were extracted and compared between the E and L groups. In all tasks, the E group had significantly shorter task durations than the L group. The E group also exhibited higher average velocity, acceleration, jerk, and normalized mean squared jerk values in several tasks, particularly showing shorter travel distances with the right instrument (Arm3) and faster, more dynamically modulated movements with the left instrument (Arm1). Further, compared with the L group, the E group had a significantly longer camera movement per scope pedal press and significantly fewer wrist articulations in the suturing tasks. Experienced manipulation in robotic surgery is characterized by shorter instrument travel distances, intentional modulation of movement speed, and minimal wrist articulation. Quantitative evaluation of operative characteristics using log data can contribute to future applications in surgical training and skill assessment.
To evaluate national trends and clinical outcomes of donation after circulatory death (DCD) simultaneous liver-kidney transplantation (SLKT) in the US, particularly in the modern era following adoption of machine perfusion (MP) and normothermic regional perfusion (NRP). Utilization of DCD donors for liver transplantation has increased substantially in the US, and MP and NRP were reported to reduce complications, including reperfusion syndrome and early allograft dysfunction. However, national trends and outcomes of DCD-SLKT in the contemporary era of organ perfusion have not been characterized. Using UNOS STAR files, we analyzed 10.687 adult primary SLKT performed between 2000 and 2025. Outcomes of DCD and donation after brain death (DBD) SLKT during 2020-2025 were compared using propensity score matching (PSM) to adjust for donor and recipient characteristics. Kaplan-Meier methods were used to assess graft/patient survival. The utilization of DCD-SLKT increased markedly after 2018, accounting for 29.3% of all SLKT cases in 2024. In 2024, liver MP, kidney MP, and NRP were used in 58.1%, 82.9%, and 40.1% of DCD-SLKT cases. Before matching, recipients in the DBD-SLKT group more frequently required dialysis at transplantation (69.1% vs 54.2%) and were hospitalized preoperatively (51.0% vs 17.2%), and had higher MELD scores (30 vs 23) during 2020-2025. Median follow-up was shorter in DCD-SLKT (706 vs 364 days), reflecting the more recent adoption of DCD transplantation. Liver graft/patient survival were comparable between DCD- and DBD-SLKT regardless of PSM. Utilization of DCD donors for SLKT has increased substantially in parallel with the expanding use of MP and NRP, with graft/patient outcomes comparable to those of DBD-SLKT regardless of PSM. However, DBD-SLKT recipients had higher baseline preoperative risk. These support broader adoption of DCD donors for SLKT in appropriately selected recipients.
Oncological resectability classification for hepatocellular carcinoma (HCC) emphasizes the need to reassess treatment strategies for borderline resectable (BR) cases. This study evaluated surgical outcomes and prognostic factors in BR-HCC and reconsidered multidisciplinary approaches for recurrence management. The study comprised 433 patients who underwent primary hepatic resection for HCC between 2000 and 2023. Patients were classified as R, BR1, and BR2 according to the Expert Consensus Statement 2023. Multivariate Cox proportional hazard models were conducted to identify prognostic factors for disease-free and overall survival in BR (BR1 + BR2) patients. Among 70 patients with BR-HCC (BR1: n = 37, BR2: n = 33), 5-year overall survival was 53% in BR1 versus 22% in BR2 patients (p = 0.06). In multivariate analysis, up-to-7 out (p < 0.001) and lymph node metastasis (p < 0.001) were independent predictors of cancer recurrence, whereas anatomical resection was associated with improved disease-free survival (p = 0.02). Independent predictors of overall survival included older age (p = 0.01), Child-Pugh B (p < 0.001), up-to-7 out (p = 0.01), macrovascular invasion (p = 0.01), and lymph node metastasis (p < 0.001). Recurrence occurred in 89% of BR-HCC patients, with BR2 showing more frequent early recurrence within 1 year (p = 0.006) and recurrence beyond Milan criteria (p = 0.02) compared to BR1. Patients receiving surgical resection or radiofrequency ablation for recurrence demonstrated better survival compared with other treatments (p < 0.001). BR1 and BR2-HCC represent biologically aggressive subsets with high recurrence rates and poor prognosis, particularly in tumors with up-to-7 out status, lymph node metastasis, and macrovascular invasion. Active salvage treatment for recurrence may improve survival, highlighting the importance of multidisciplinary approaches in BR-HCC management.
In the assessment of criminal insanity, delusions play a particularly important role, because they express reality judgments, which, due to their verbalized form, serve well as "evidence" of psychosis. However, psychosis, understood as a fundamentally impaired sense of reality, can also involve disturbances that are neither verbalized nor inferential, but mainly enacted. In this paper, we revisit the psychopathological concept of "senseless actions", employed by the German psychiatrist Klaus Conrad to describe the unintelligible actions observed in individuals in the early phase of schizophrenia. The forensic relevance of this concept is illustrated with a historical case study from the annals of Karl Wilmanns. We discuss how "senseless actions" express a global disturbance in the individual's way of finding relevance, meaning, and constraint in the world, and argue that "senseless actions" may function as a behavioral indicator of the transition between a prodromal phase and manifest psychosis - pointing again to its forensic relevance. We stress the importance of considering contextual information and adopt a Gestalt view of how the actions inscribe themselves in the biography of the individual when determining whether "senseless actions" are indicative of psychosis. In conclusion, we suggest that the concept of "senseless action", though imperfect and context sensitive, may offer a framework for identifying disturbances in reality understanding that risk being marginalized in contemporary approaches to criminal insanity.
The integration of artificial intelligence (AI) into research and publishing poses ethical challenges. Global editorial associations, including the International Committee of Medical Journal Editors (ICMJE), have updated their recommendations to safeguard transparency and accountability for AI use. The extent to which these recommendations have been enforced in specialist journals remains unknown. The aim of our study was to analyze the extent to which indexed rheumatology journals have adopted AI-related editorial policies, the scope of these policies, and their alignment with ICMJE recommendations. A total of 58 impact-factor rheumatology journals were analyzed in view of their AI-related editorial policies. Author instructions, ethics statements, and publisher guidelines were overviewed for (1) AI-related instructions; (2) alignment with ICMJE recommendations; (3) provisions regulating AI use by authors, peer reviewers, and editors; and (4) regulations concerning generative text, images, data, and analytical outputs. Of the 58 journals, 45 (77.6%) presented explicit AI editorial policies, while 13 (22.4%) lacked any AI-related guidance. The majority of journals (98.2%) endorsed ICMJE points on AI. High-impact journals-Nature Reviews Rheumatology, The Lancet Rheumatology, and Annals of the Rheumatic Diseases-demonstrated the most stringent governance, prohibiting AI use for analytical and creative roles, mandating detailed disclosure of AI tools and prompts, and banning AI use for peer review and editorial decision-making. The guidance on AI use by peer reviewers and editors was present in 45 journals (77.6%). Permissive uses of AI were largely confined to language editing under human supervision. Generative or substantive uses-such as producing figures, conceptual contents, or data-were broadly restricted. Indexed rheumatology journals demonstrate variable editorial policies of enforcing AI guidance. While the adoption of AI-related policies is mostly improving, a marked heterogeneity still exists, particularly between top-tier and lower-tier journals. Upgrades of editorial policies are warranted to safeguard the integrity and transparency of rheumatology sources.