Designed and implemented over two decades ago, the Chronic Care Model is a well-established chronic disease management framework that has steered several healthcare systems in successfully improving the clinical outcomes of patients with type 2 diabetes mellitus. Research evidence cements the role of the Chronic Care Model (with its six key elements of organization of healthcare delivery system, self-management support, decision support, delivery system design, clinical information systems, and community resources and policies) as an integrated framework to revamp the type 2 diabetes mellitus-related clinical practice and care that betters the patient care and clinical outcomes. The current review is an evidence-lit summary of importance of use of Chronic Care Model in primary care and their impact on clinical outcomes for patients afflicted with one of the most debilitating metabolic diseases, type 2 diabetes mellitus.

The contemporary literature provides conflicting evidence regarding the precedence of laparoscopic mesh rectopexy over laparoscopic suture rectopexy for full-thickness rectal prolapse. This study aimed to compare the clinical outcomes of mesh and suture rectopexy to improve the surgical management of complete rectal prolapse. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed to extract studies based on mesh versus suture rectopexy and published from 2001 to 2023. The articles of interest were obtained from PubMed Central, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Journal Storage (JSTOR), Web of Science, Embase, Scopus, and the Cochrane Library. The primary outcomes included rectal prolapse recurrence, constipation improvement, and operative time. The secondary endpoints included the Cleveland Clinic Constipation Score, Cleveland Clinic Incontinence Score, intraoperative bleeding, hospital stay duration, mortality, overall postoperative complications, and surgical site infection. A statistically significant low recurrence of rectal prolapse (odds ratio: 0.41, 95% confidence interval (CI) 0.21-0.80; p=0.009) and longer mean operative duration (mean difference: 27.05, 95% CI 18.86-35.24; p<0.00001) were observed in patients with mesh rectopexy versus suture rectopexy. Both study groups, however, had no significant differences in constipation improvement and all secondary endpoints (all p>0.05). The laparoscopic mesh rectopexy was associated with a low postoperative rectal prolapse recurrence and a longer operative duration compared to laparoscopic suture rectopexy. Prospective randomized controlled trials should further evaluate mesh and suture rectopexy approaches for postoperative outcomes to inform the surgical management of complete rectal prolapse.

BACKGROUND: Total neoadjuvant therapy (TNT) in the management of locally advanced rectal cancer (LARC) did not show survival benefit over the standard long course chemoradiotherapy. Trials of TNT did not address the impact of each risk feature in isolation from other high-risk features.
METHODS: In this retrospective study, we describe the clinical outcomes of patients with T4 and/or N2 rectal adenocarcinoma who were treated with chemoradiotherapy followed by total mesorectal excision (TME). After obtaining the local regulatory approvals, demographic and clinical data were collected for patients in Manitoba between January 2007 and December 2019.
RESULTS: The cohort included 331 patients. 61 patients had T4-only disease and 218 had N2-only disease. Mean age was 59.65 years. 74.3% received adjuvant chemotherapy (ACT), but only 56.5% completed the planned course. R0 resection was achieved in 93.4% of patients (78.7% and 97.2% in T4 and N2, respectively). Median follow up was 4.93 years. 3-year overall recurrence rate was 29%. 3-year locoregional recurrence (LRR) rate was 8% (16% and 6% in T4 and N2, respectively). 3-year overall survival (OS) rate was 84% in the whole cohort (72.6% and 87.1% in T4 and N2, respectively). Incomplete surgical resection was a poor prognostic factor for both OS and LRR. ACT was associated with a survival benefit in the whole cohort (P = .001) and in the N2 sub-cohort (P = 003) but there was no survival benefit observed in T4 sub-cohort. ACT did not have an impact on LRR.
CONCLUSIONS: Achieving R0 resection in LARC with neoadjuvant therapy improves recurrence and survival rates. T4 disease carries a worse clinical outcome than N2 and consideration should be given to upstage T4 to stage III. Different high-risk features in LARC predict different clinical outcomes. In the era of TNT, personalization of treatment strategy based on these factors could potentially improve outcomes.

OBJECTIVE: To report on the recovery of strength and functional capacity symmetry following multiligament knee surgical reconstruction (MLKR), as well as the capacity of athletes to return to sport.
METHODS: This prospective cohort study recruited 47 patients undergoing MLKR between February 2018 and July 2021. Forty patients had full outcome assessment postoperatively at 6, 12 and 24 months and were included in the analysis, 75% were knee dislocation one injuries and 60% were injured playing sport. Patient-reported outcome measures (PROMs) assessed included the International Knee Documentation Committee score, the Knee Outcome Survey, the Lysholm Knee Score and the Tegner Activity Scale (TAS). Patient satisfaction was also assessed. Objective assessment included assessment of active knee flexion and extension range of motion (ROM), the single (single horizontal hop for distance [SHD]) and triple (triple horizontal hop for distance [THD]) hop tests for distance and peak isokinetic knee flexor/extensor torque.
RESULTS: All PROMs significantly improved (p < 0.001) from presurgery to 24 months postsurgery. At 24 months, 70% of patients were satisfied with their sports participation. Active knee flexion (p < 0.0001) and extension (p < 0.0001) ROM significantly improved over time, as did the limb symmetry indices (LSIs) for the SHD (p < 0.0001), THD (p < 0.0001), peak knee extensor (p < 0.0001) and flexor (p = 0.012) torque. While LSIs for the SHD, THD and knee flexor strength tended to plateau by 12 months, knee extensor strength continued to improve from 12 to 24 months.
CONCLUSIONS: The majority of patients undergoing modern MLKR surgical techniques and rehabilitation can achieve excellent knee function, with low complication rates.
METHODS: Level IV.

BACKGROUND: This analysis examined the baseline characteristics and clinical outcomes of patients with chronic kidney disease (CKD) and rapid or non-rapid estimated glomerular filtration rate (eGFR) decline, using retrospective data from DISCOVER CKD (ClinicalTrials.gov, NCT04034992).
METHODS: Data (2008-2020) were extracted from UK Clinical Practice Research Datalink, US TriNetX, US Limited Claims and Electronic Health Record Dataset, and Japan Medical Data Vision. Patients with CKD (two consecutive eGFR measures < 75 mL/min/1.73 m2 recorded 90-730 days apart) were included. Rapid eGFR decline was defined as an annual decline of > 4 mL/min/1.73 m2 at 2 years post-index; non-rapid eGFR decline was defined as an annual decline of ≤ 4 mL/min/1.73 m2. Clinical outcomes assessed included all-cause mortality, kidney outcomes (composite risk of kidney failure [progression to CKD stage 5] or > 50% eGFR decline, and kidney failure alone), cardiovascular events-including major adverse cardiovascular events (MACE; non-fatal myocardial infarction/stroke and cardiovascular death)-and all-cause hospitalization.
RESULTS: Across databases, rapid eGFR decline occurred in 13.7% of 804,237 eligible patients. Mean annual eGFR decline ranged between - 6.21 and - 6.86 mL/min/1.73 m2 in patients with rapid eGFR decline versus between - 0.11 and - 0.77 mL/min/1.73 m2 in patients with non-rapid eGFR decline. Rapid eGFR decline was associated with increased comorbidity burden and medication prescriptions. Across databases, the composite risk of kidney failure or > 50% decline in eGFR was significantly greater in patients with rapid versus non-rapid eGFR decline (P < 0.01); all-cause mortality, kidney failure alone, MACE, and all-cause hospitalization each significantly increased in two databases (P < 0.01-0.05).
CONCLUSIONS: Understanding patient factors associated with rapid eGFR decline in patients with CKD may help identify individuals who would benefit from proactive management to minimize the risk of adverse outcomes.
BACKGROUND: ClinicalTrials.gov identifier, NCT04034992.

OBJECTIVE: Continued play following concussion can lead to worse outcomes and longer recoveries compared with athletes who immediately report. This has been well documented in youth athletes, while less attention has been paid to collegiate athletes despite differences in healthcare access, recovery trajectories, and additional pressures to play. Therefore, the purpose of this study was to determine if continuing to play immediately following a concussion influenced clinical outcomes and recovery time in collegiate athletes.
METHODS: A prospective, repeated-measures design was used to compare clinical outcomes and recovery time between collegiate athletes who continued playing (n = 37) and those immediately removed (n = 56) after a concussion. Assessments were conducted within 5 days of the concussion and at full medical clearance (FMC; ± 3 days) using the Sport Concussion Assessment Tool-5th edition (SCAT5), Vestibular/Ocular Motor Screening assessment, and High-Level Mobility Assessment Tool. Mann-Whitney U-tests determined differences in clinical outcomes between groups. Cox proportional hazards regression models examined the relationship between factors associated with days to symptom resolution and days to FMC, and covariates were selected a priori based on previous literature. Hazard ratios with 95% CIs were reported for each predictor variable.
RESULTS: Significant differences were found in SCAT5 concentration composite scores (p = 0.010) and SCAT5 delayed recall composite scores (p = 0.045) at the acute visit and near point of convergence average distance (cm; p = 0.005) at the FMC visit between the group who continued to play and those who were immediately removed. There were no differences between groups in days to symptom resolution (10 vs 7 days, p = 0.05) and days to clearance (13 vs 11.50 days, p = 0.13). The association between groups and days to symptom resolution (χ2[4] = 5.052, p = 0.282), and days to clearance (χ2[4] = 3.624, p = 0.459) were not significant when adjusting for covariates.
CONCLUSIONS: Collegiate athletes who continued to play following concussion did not exhibit worse clinical outcomes or recovery times compared with athletes who were immediately removed. While the lack of differences found in this study could be supported by prior literature, including improved education, awareness, reporting attitudes, and concussion management at the collegiate level in recent years, the authors believe discrepancies are more likely due to study-specific differences (e.g., sample size, care setting, and timing). Therefore, these findings should not diminish the dangers of continued play and the importance of timely removal after concussion.

Robotic total knee replacement (TKR) surgery has evolved over the years with the aim of improving the overall 80% satisfaction rate associated with TKR surgery. Proponents claim higher precision in executing the pre-operative plan which results in improved alignment and possibly better clinical outcomes. Opponents suggest longer operative times with potentially higher complications and no superiority in clinical outcomes alongside increased costs. This editorial will summarize where we currently stand and the future implications of using robotics in knee replacement surgery.

UNASSIGNED: Percutaneous transforaminal endoscopic discectomy (PTED) was used as a minimally invasive treatment option for lumbar disc herniation (LDH). However, studies focusing on the clinical outcomes of PTED for elderly patients with adjacent segment disease (ASD) were limited. This study aims to compare the clinical outcomes of PTED between ASD and LDH in elderly patients.
UNASSIGNED: This retrospective study enrolled 39 patients with ASD and 39 patients with LDH. Both groups had undergone PTED in Beijing Chaoyang Hospital from July 4, 2016 to July 30, 2021. Visual analog scale for back pain (VAS-BP) and leg pain (VAS-LP) and Oswestry disability index (ODI) were used to value the clinical outcomes of patients preoperatively, immediately postoperatively, 12, and 24 months postoperatively, and at final follow-up. Patients\' satisfaction was evaluated based on the MacNab criteria.
UNASSIGNED: All operations were completed. The excellent or good clinical outcomes at final follow-up was demonstrated by 87.15% (34/39) and 89.74% (35/39) in ASD and non-ASD patients, respectively. Clinical improvement was observed immediately postoperatively in both groups and sustained stability during the postoperative follow-up. The ASD group demonstrated significantly longer hospital stays (p = 0.02) and operative time (p < 0.01) than the non-ASD group.
UNASSIGNED: PTED is an effective and minimally invasive treatment option for revision surgery of ASD, especially for elderly patients. However, the long-term prognosis of PTED treating ASD still needs further exploration.

BACKGROUND: Boarding time in the Emergency Department (ED) is an area of concern for all patients and potentially more problematic for the hip fracture population. Identifying patient outcomes impacted by ED boarding and improving emergent care to reduce surgical delay for this patient population is a recognized opportunity. The objective of this study is to examine the impact of ED boarding in relation to patient outcomes in the surgical hip fracture population.
METHODS: This is a retrospective study of hip fracture patients who presented at the ED of a Level 1 trauma center between January 2020 and December 2021. Patients were categorized into four quartiles based on boarding time. Study outcomes-hospital length of stay, time to surgery, visit to ICU post-operative, total blood products, in-hospital complications, discharge disposition, in-hospital mortality, and 30-day readmission-were compared among these four quartiles.
RESULTS: The outcome endpoints were comparable among the four quartiles except for time to surgery. Time to surgery significantly differed among the quartiles, increasing from 20.39 to 29.03 h (p < 0.001) from the first to fourth quartile.
CONCLUSIONS: In contrast to the existing literature, ED boarding in our study was not associated with adverse outcomes except for time to surgery. By expediting the time to surgery in accordance with established guidelines, adverse outcomes were mitigated even when our patients boarded for a longer duration. System processes including a 24/7 trauma nurse practitioner model, availability of in-house orthopedic surgeons, and timely cardiac evaluation need to be considered in relation to time to surgery, in turn impacting ED boarding and patient outcomes.

OBJECTIVE: Functional hemispherectomy is an effective surgical intervention for select patients with drug-resistant epilepsy. The last several decades have seen dramatic evolutions in preoperative evaluation, surgical techniques, and postoperative care. Here, the authors present a retrospective review of the medical records of 146 children who underwent hemispherectomy between 1987 and 2022 at The Hospital for Sick Children, providing a unique overview of the evolution of the procedure and patient outcomes over 35 years.
METHODS: The medical records of all children who underwent hemispherectomy at The Hospital for Sick Children between 1987 and 2022 were reviewed. Demographic information, preoperative clinical features, short-term and long-term seizure outcomes, and details regarding postoperative complications were recorded.
RESULTS: The seizure outcomes of 146 children were analyzed. There were 68 females and 78 males with a mean age of 5.08 years, 123 of whom demonstrated seizure freedom (Engel class IA) in the short-term postoperative follow-up period and 89 in the long term. The effectiveness of hemispherectomy in achieving long-term seizure control has improved over time (β = 0.06, p < 0.001). Factors associated with overall seizure freedom included younger age at the time of hemispherectomy and stroke as the etiology of seizures, as well as complete disconnection during the first surgery. Additionally, the etiologies of epilepsy for which hemispherectomy is performed have expanded over time, while complication rates have remained unchanged.
CONCLUSIONS: Hemispherectomy is an increasingly effective treatment for certain cases of drug-resistant epilepsy. The etiologies of epilepsy for which hemispherectomy is performed are broadening, with no change in its safety profile. Seizure outcomes are better when the etiology of epilepsy is an ischemic injury, and the most common complication after the procedure is hydrocephalus. These findings reinforce the ongoing use of hemispherectomy as a safe and effective treatment option for certain individuals with drug-resistant epilepsy, support its application to a broader range of etiologies, and highlight areas of future investigation.