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BACKGROUND:The "difficult gallbladder" in acute cholecystitis can preclude safe achievement of the critical view of safety, prompting subtotal cholecystectomy (STC) as a guideline-supported bailout. We performed a contemporary synthesis to clarify STC's safety effectiveness trade-offs vs total cholecystectomy (TC) and delineate technique-specific outcomes and patient factors that may influence risk. METHODS:We conducted a systematic review and meta-analysis of studies from 2010 to June 2025. Three comparisons were evaluated: (i) single-arm outcomes after STC, (ii) STC vs TC, and (iii) fenestrating STC (f-STC) vs reconstituting STC (r-STC). Random-effects models were applied, with prespecified subgroup analyses, leave-one-out sensitivity analyses, and exploratory meta-regression. RESULTS:In single-arm analysis, bile duct injury (BDI) occurred in 0.3%, bile leak in 13.5%, retained stones in 6.1%, and overall complications in 24.7% of patients. Readmission and reoperation occurred in 17.8% and 6.3%, whereas mortality was 0.8%. Postprocedural endoscopic retrograde cholangiopancreatography (ERCP) occurred in 16.2%, and percutaneous drainage in 5.7%. Compared with TC, STC had significantly higher bile leak, retained stones, overall complications, readmission, reoperation, and ERCP, with no significant difference in mortality, intensive care unit admission, or length of stay (LOS). Meta-regression linked diabetes with higher leak, complications, and ERCP, and male sex with higher surgical site infection. f-STC had significantly higher bile leak and longer LOS than r-STC, with ERCP trending higher. CONCLUSION:STC carries a very low BDI rate, but higher postoperative morbidity and secondary interventions than TC. r-STC demonstrated superior outcomes to f-STC. Diabetes and male sex were important risk modifiers. STC remains a rational bailout when the critical view cannot be achieved.
SGLT2 inhibitors (SGLT2i) and GLP-1 receptor agonists (GLP-1RA) reduce cardiovascular and metabolic risks in type-2 diabetes, cardiovascular disease, and obesity, yet social determinants of health (SDOH) may influence access to these therapies. We conducted a systematic review and meta-analysis to assess whether SDOH—socioeconomic status (SES), insurance status, education, geography, neighborhood deprivation—and demographic characteristics—race and sex—are associated with differential utilization of SGLT2i or GLP-1RA. Six databases (Ovid MEDLINE, Ovid Embase, Scopus, Web of Science, Cochrane Library, and Google Scholar) were searched through February 2025. Retrospective and cross-sectional studies reporting association between at least one SDOH and prescription of SGLT2i and/or GLP-1RA were included. The primary outcome was the adjusted odds of utilization of SGLT2i, GLP-1RA, or both drugs by SDOH categories. Meta-analyses were conducted separately for SGLT2i and GLP-1RA using random-effects models. Risk of bias was assessed using ROBINS-I. Twenty-six studies (> 14.6 million patients) were included. Low-SES patients had reduced odds of utilization (aOR 0.73; 95
Background/Objectives: Diagnostic evaluation and management of nontraumatic osteonecrosis of the femoral head (ONFH) vary substantially. This systematic review was conducted to inform development of the Association Research Circulation Osseous (ARCO) clinical practice guideline for diagnosis and treatment of ARCO stages I to III ONFH. Methods: We searched MEDLINE, EMBASE, Web of Science, SCOPUS, Global Index Medicus, and the Cochrane Library for studies evaluating imaging modalities and treatments for adult ONFH. We assessed risk of bias using the QUADAS-2, the ROB-2, and the ROBINS-I tools; conducted meta-analyses using random-effects regression; and evaluated certainty of evidence using GRADE methodology. Results: Among 36 included studies, 18 addressed diagnostic test accuracy and 18 addressed comparative effectiveness of treatments. Magnetic resonance imaging (MRI) demonstrated the highest pooled sensitivity (0.91; 95% confidence interval (CI), 0.87 to 0.94) and specificity (0.96; 95% CI, 0.87 to 0.99) for ONFH diagnosis. Bone marrow edema and grade 2+ joint effusion on MRI differentiated symptomatic versus asymptomatic disease. Computed tomography and MRI better detected subchondral fractures than plain radiography. Very low-grade evidence suggested lower rates of femoral head collapse with core decompression plus bone marrow concentrate compared with core decompression alone (pooled relative risk [RR], 0.55; 95% CI, 0.36 to 0.83), and with vascularized versus non-vascularized bone grafting (RR, 0.35; 95% CI, 0.14 to 0.84) over a ≤5-year follow-up. Based on three non-comparative case series, osteotomies might have a lower risk of collapse over a 10- to 20-year follow-up, but this needs to be evaluated in future comparative research. Inconsistent outcome reporting hindered treatment outcome pooling. There were no comparative studies that evaluated observation only versus intervention in asymptomatic disease or strategies for monitoring treatment response. Conclusions: Evidence supporting optimal imaging modalities and early joint-preserving interventions remains limited and predominantly observational, underscoring the need for high-quality comparative studies with consistently defined core outcomes to guide clinical decision-making.
The United States is experiencing a high societal burden of pregnancy-related and infant morbidity and mortality during the postnatal year. These trends are inherently linked because the 2 members of the parent-infant dyad are interdependent for their well-being. Several systemic factors contribute to suboptimal health outcomes, including health care siloes under the medical specialization paradigm, multiple care transitions, and lack of care coordination during the postnatal year. Despite the clear positive impact of breastfeeding on parent and child health outcomes, as a dyadic specialty, lactation care does not have an obvious home within the siloed United States health care system. The objective of this article is to propose implementation of a comprehensive dyadic care model for birthing parents and infants during the postnatal year, including a focus on provider-level lactation management. Practical issues, such as clinic workflows, financial sustainability, workforce development solutions, and scope of practice issues are discussed. Midwives are ideally positioned to be leaders in the provision of dyadic perinatal care during the postnatal year, with long-term implications for parent and infant health.
BACKGROUND:The development of international clinical practice guidelines offers an opportunity to harmonize evidence-based care across diverse health-care systems but presents substantial logistical, methodological, and implementation challenges. These challenges are particularly pronounced for nontraumatic osteonecrosis of the femoral head, a condition characterized by heterogeneous disease biology, evolving diagnostic criteria, and limited high-certainty evidence. METHODS:This article summarizes key lessons learned during the development of the first international, evidence-based clinical practice guidelines for osteonecrosis of the femoral head led by the Association Research Circulation Osseous. RESULTS:Key lessons emerged across multiple domains, including optimization of panel structure and workflow, effective use of virtual collaboration platforms, early engagement of methodological experts, refinement of literature search and data abstraction approach, and staged formulation and approval of recommendations. Additional insights highlighted the need to anticipate global variability in resources, language, and clinical context, underscoring the value of resource-stratified recommendations, early planning for translation and cultural adaptation, incorporation of patient values and preferences, and linkage of guideline recommendations to measurable quality indicators to assess real-world uptake and impact. CONCLUSIONS:The lessons learned emphasize that international guideline development should adopt a life cycle approach extending beyond publication to promote equitable adoption, continuous refinement, and meaningful improvements in patient care worldwide.
