Exercise Therapy and Education Improve Short-Term Outcomes After ACL Reconstruction
A randomized trial of 184 young adults with persistent knee symptoms after ACL reconstruction found that 4 months of supervised exercise and education produced greater short-term improvements in pain, function, and quality of life than minimal education and self-directed exercise. Benefits narrowed by 12 months, while no difference in cartilage thickness was observed between groups.
KEY FINDINGS: In young adults with persistent knee symptoms after ACL reconstruction, a 4-month supervised exercise and education program produced greater short-term improvements in knee pain, symptoms, function, and quality of life than minimal education and self-directed exercise. The treatment difference diminished by 12 months, and no difference in cartilage thickness was observed, providing trial evidence that the supervised exercise program did not result in detectable adverse changes in this structural measure over the study period. The findings support the potential value of structured rehabilitation for patients who continue to experience knee problems after the usual postoperative rehabilitation period.
BACKGROUND: Persistent pain, functional limitations, and reduced quality of life can continue in young adults after anterior cruciate ligament reconstruction (ACLR), increasing concern about early post-traumatic knee osteoarthritis. The SUPER-Knee randomized clinical trial evaluated whether a structured, physiotherapist-supervised exercise and education program could improve knee symptoms and function in young adults with ongoing problems after ACLR, while also examining whether exercise affected knee cartilage.
DETAILS: The randomized clinical trial enrolled 184 adults aged 18 to 40 years who remained symptomatic 9 to 36 months after ACL reconstruction. Participants were randomly assigned to either a 4-month individualized program of twice-weekly, physiotherapist-supervised strengthening and neuromuscular exercise with education or a minimal-intervention group receiving a one-time education session and advice for self-directed exercise. The primary outcome was change in the Knee injury and Osteoarthritis Outcome Score (KOOS4), which incorporates pain, symptoms, function in sports and recreational activities, and knee-related quality of life. Secondary outcomes included patient-perceived recovery, thigh muscle strength, and MRI measures of cartilage.
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Of the 184 participants, 92 were assigned to each group; 178 participants (97%) completed the 4-month assessment and 174 (95%) completed the 12-month assessment. At 4 months, KOOS4 scores improved by 14.1 points in the supervised exercise group compared with 9.3 points in the minimal-intervention group, corresponding to an adjusted between-group difference of 4.8 points (95% CI, 1.4 to 8.2). The difference was smaller at 12 months, with an adjusted between-group difference of 1.4 points (95% CI, -2.0 to 4.8). Participants receiving supervised exercise also had greater improvements in thigh muscle strength and were more likely to report that their knee had improved. The odds of reporting improvement were 5.2 times higher at 4 months (95% CI, 2.7 to 10.0) and 2.5 times higher at 12 months (95% CI, 1.3 to 4.9). MRI assessment showed no between-group difference in cartilage thickness.
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Source: Culvenor, A. G., Bruder, A. M., West, T., et al. XXExercise Therapy and Education for Young Adults With Persistent Knee Problems After Anterior Cruciate Ligament Reconstruction: A Randomized Clinical Trial. Annals of Internal Medicine. Published: September 29, 2026. DOI: 10.7326/ANNALS-26-02460.
Timing of Vascular Access Creation in Older Adults With ESKD
A prospective European cohort of older adults with ESKD found that only 32% of AVFs were created within the defined 6-month window before hemodialysis initiation, while 42% were created early and 26% late. The findings highlight the difficulty of predicting dialysis timing and the need for better tools to individualize vascular access planning.
KEY FINDINGS: In this European cohort of older adults with ESKD, vascular access creation frequently did not coincide with the timing of hemodialysis initiation. More than 4 in 10 AVFs were created early, while approximately 1 in 4 were created late, resulting in substantial use of CVCs at dialysis initiation. The findings highlight the difficulty of predicting dialysis initiation in older adults and support the development of clinical prediction tools to better individualize vascular access planning.
BACKGROUND: Planning vascular access for older adults with end-stage kidney disease (ESKD) is challenging because the timing of hemodialysis initiation is difficult to predict. Arteriovenous fistulas (AVFs) created too early may remain unused, whereas delayed creation can result in hemodialysis being initiated through a central venous catheter (CVC). This study evaluated the timing of vascular access creation relative to hemodialysis initiation in older patients across Europe.
DETAILS: This secondary analysis used data from the EQUAL cohort, a prospective observational study involving patients aged 65 years or older with stage 4 or 5 chronic kidney disease in six European countries. Patients were included when their estimated glomerular filtration rate fell below 15 mL/min/1.73 m², provided they received a vascular access and had at least 6 months of follow-up. AVF timing was categorized as early when hemodialysis did not begin within 6 months after AVF creation, on time when hemodialysis was initiated with an AVF within 6 months, and late when hemodialysis was initiated with a CVC before or within 6 months after AVF creation.
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A total of 332 patients were analyzed. An AVF was the first vascular access in 221 patients (67%), while 111 patients (33%) initially received a CVC. Among those initially receiving a CVC, 53 patients (48%) subsequently underwent AVF creation. At dialysis initiation, 158 patients (54%) were using an AVF and 136 (46%) were using a CVC. Among the 274 patients who underwent AVF creation, access was created on time in 88 patients (32%), early in 114 (42%), and late in 72 (26%). Despite the high proportion of early AVF creation, most fistulas were eventually used, with 90% of patients initiating hemodialysis within 3 years after AVF creation.
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Source: Heggen, B. D. C., Chesnaye, N. C., Dekker, F. W., et al. Vascular Access Surgery Timing: A Prospective European Cohort Study in Elderly Patients with ESKD. Kidney360. 2026; 7(9): 2066-2074. Published: September 22, 2026. DOI: 10.34067/KID.0000001180.
AI-Assisted Colonoscopy for Colorectal Lesion Detection in Lynch Syndrome
A multicentre randomized trial of 733 patients with Lynch syndrome found that AI-assisted colonoscopy did not significantly increase adenoma detection compared with high-definition white-light colonoscopy alone (33.8% vs 30.9%; P=0.41). AI-based lesion characterization showed good sensitivity and specificity but did not clearly improve on expert optical diagnosis in specialized surveillance settings.
KEY FINDINGS: In this international randomized trial conducted at specialized Lynch syndrome surveillance centres, adding AI-assisted detection to high-definition white-light colonoscopy did not significantly increase adenoma detection. Although the CADx system demonstrated good sensitivity and specificity for lesion differentiation, it did not clearly provide an advantage over expert optical diagnosis in this specialist setting. The findings indicate that the benefit of AI-assisted colonoscopy may depend on the expertise and clinical setting in which it is deployed.
BACKGROUND: Individuals with Lynch syndrome undergo regular colonoscopic surveillance because of their increased risk of colorectal cancer. Artificial intelligence (AI)-based computer-aided detection (CADe) has improved adenoma detection in average-risk colorectal cancer screening, but evidence in Lynch syndrome surveillance has been limited. The CADLY2 trial evaluated whether AI-assisted colonoscopy could improve adenoma detection and whether computer-aided optical diagnosis (CADx) could accurately differentiate neoplastic from non-neoplastic colorectal lesions.
DETAILS: This international, multicentre, open-label, randomized controlled trial was conducted at nine specialized hereditary cancer surveillance centres in Belgium, Germany, the Netherlands, and Spain. Adults aged 18 years or older with genetically confirmed Lynch syndrome undergoing surveillance colonoscopy were randomly assigned to high-definition white-light (HD-WL) colonoscopy alone or HD-WL colonoscopy assisted by the CAD EYE AI system. CADe was used during withdrawal to identify lesions, while CADx was used after lesion detection to assist with optical differentiation. The primary outcome was adenoma detection rate, defined as the proportion of patients with at least one histopathologically confirmed adenoma.
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Between May 9, 2023, and October 30, 2025, 757 patients were randomly assigned to HD-WL colonoscopy (377) or AI-assisted colonoscopy (380). The primary analysis included 733 patients: 369 in the HD-WL group and 364 in the AI-assisted group. Adenoma detection occurred in 30.9% of patients undergoing HD-WL colonoscopy compared with 33.8% receiving AI-assisted colonoscopy. The odds ratio was 1.14 (95% CI, 0.83-1.57; P=0.41), indicating no statistically significant improvement in adenoma detection with CADe. In the lesion-level analysis, CADx differentiated neoplastic from non-neoplastic lesions with a sensitivity of 85.9% (95% CI, 82.0-89.1) and specificity of 91.4% (95% CI, 89.4-93.0). Three adverse events occurred in the AI-assisted group, including two mild post-polypectomy bleeding events and one serious pulmonary embolism or deep venous thrombosis considered unrelated to the procedure. No adverse events were reported in the HD-WL group.
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Source: Hüneburg, R., van Bokhorst, Q. N. E., Pellisé, M., et al. Artificial intelligence-assisted detection and optical differentiation of colorectal lesions in Lynch syndrome surveillance (CADLY2): a multicentre, open-label, randomised controlled superiority trial. The Lancet Gastroenterology & Hepatology. 2026; 11(10): 875-886. Published: October, 2026. DOI: 10.1016/S2468-1253(26)00163-9.
Overdiagnosis of Papillary Thyroid Cancer in the United States
A US simulation study estimated that 72% to 94% of papillary thyroid cancer cases diagnosed between 1991 and 2019 were overdiagnosed. Reducing ultrasonography for nonpalpable thyroid nodules was modeled to substantially lower PTC incidence, with less than a 0.1% change in overall mortality. The findings highlight the potential role of reducing unnecessary imaging and diagnosis while recognizing that the estimates are model-based.
KEY FINDINGS: The findings indicate that PTC overdiagnosis remained substantial even after accounting for a possible underlying increase in true disease incidence. The modeling suggests that limiting unnecessary ultrasonography referrals for nonpalpable thyroid nodules could reduce detection of cancers unlikely to affect population mortality, potentially reducing unnecessary diagnoses and treatment-related burdens without a meaningful modeled increase in overall mortality. Because these findings are based on a simulation model rather than observed outcomes from an intervention, they should be interpreted as population-level estimates rather than evidence that reducing imaging is appropriate for individual patients.
BACKGROUND: Papillary thyroid cancer (PTC) incidence in the United States has increased substantially over recent decades, largely driven by detection of small, early-stage tumors, while population-level mortality has remained relatively stable. This pattern has raised concern that some thyroid cancers detected through imaging may never have become clinically significant. This study used a validated simulation model to estimate the extent of PTC overdiagnosis in the United States and examine the potential effects of reducing thyroid ultrasonography for nonpalpable thyroid nodules.
DETAILS: Researchers used the Papillary Thyroid Carcinoma Microsimulation Model (PATCAM) to evaluate PTC incidence among US adults aged 18 years or older from 1991 through 2019. The model accounted for changes in underlying thyroid cancer risk and estimated the proportion and absolute number of PTC cases considered overdiagnosed, defined in the model as cancers whose detection and treatment did not affect population mortality. The investigators also modeled the potential effects of reducing thyroid ultrasonography referrals for nonpalpable thyroid nodules.
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Between 1991 and 2019, the model estimated that 72% to 94% of diagnosed PTC cases were overdiagnosed. The estimated proportion was 75% to 95% among women and 63% to 90% among men. The corresponding absolute rate of overdiagnosis was 13 to 17 per 100,000 women and 3 to 5 per 100,000 men, translating to an estimated 443,212 to 573,705 women and 107,804 to 154,504 men overdiagnosed with PTC during the 28-year period. The model further estimated that reducing thyroid ultrasonography for nonpalpable nodules by 33% would reduce PTC incidence in 2019 by 17%, from 18 to 15 per 100,000 individuals. A 67% reduction in ultrasonography was associated with a modeled 41% reduction in incidence, from 18 to 11 per 100,000. In both scenarios, the modeled change in overall mortality was less than 0.1%.
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Source: Francis, D. O., Davies, L., Zhang, Y., et al. Overdiagnosis of Papillary Thyroid Cancer. JAMA Network Open. 2026; 9(2): e2559852. Published: February 24, 2026. DOI: 10.1001/jamanetworkopen.2025.59852
Palliative Extracorporeal Membrane Oxygenation Decannulation: An Ethical, Evidence-Based Approach
A structured approach to ECMO de-escalation and decannulation can reduce practice variability while incorporating patient and family preferences. Proactive symptom management may improve the patient and family experience, supporting a more comfortable and dignified end-of-life journey.
KEY FINDINGS: A structured, interprofessional approach to palliative ECMO de-escalation can reduce variability in end-of-life practice and support more consistent symptom management and communication. Incorporating patient and family preferences into the process, together with proactive symptom management and staff debriefing, was associated with a more comfortable and dignified end-of-life experience in this quality-improvement setting.
BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is an invasive, potentially lifesaving therapy associated with complications involving multiple organ systems. When ECMO is no longer considered beneficial, de-escalation or decannulation may be required as part of a transition to comfort-focused care and natural death. At a tertiary care facility with 64 beds using ECMO, variability was identified in ECMO initiation, communication with patients and families, determination of nonbeneficial therapy, and symptom management during de-escalation.
DETAILS: This quality-improvement project integrated palliative care, reviewed existing literature on best practices, and established an interprofessional task force focused on ECMO de-escalation. New clinical guidelines were developed to provide a consistent, evidence-based framework for communication, decision-making, symptom management, and de-escalation/decannulation. The initiative was designed to reduce practice variability while improving the experience of patients, families, and clinicians during transition to comfort-directed care.
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Implementation of the guidelines decreased practice variability and reduced patient and family stress and discomfort during ECMO de-escalation and decannulation. Team members reported decreases in symptoms of secondary trauma and moral distress associated with these situations. They also reported improved delivery of end-of-life care, including family education and support, patient advocacy, and symptom management. Family members valued greater attention to both patient and family well-being, while structured staff debriefings supported reflection and identification of opportunities for improvement.
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Source: Arbour, R., Abate, M., Garcia, O., et al. Palliative Extracorporeal Membrane Oxygenation Decannulation: An Ethical, Evidence-Based Approach. Critical Care Nurse. 2026; 46(4): 17-28. Published: August 1, 2026. DOI: 10.4037/ccn2026166.
Depressive Symptoms Associated With Cognitive Impairment in Cerebral Amyloid Angiopathy
A study of 168 adults found that patients with cerebral amyloid angiopathy had substantially more depressive symptoms and poorer cognitive performance than cognitively normal controls. Possible depression was associated with impairment in episodic memory, executive function, and processing speed, and partially mediated the relationship between CAA and cognition. Greater depressive symptoms were also associated with MRI markers of cortical and small-vessel brain injury.
KEY FINDINGS: People with CAA in this study had substantially more depressive symptoms and poorer cognitive performance than cognitively normal controls. Depressive symptoms explained a small but significant portion of the association between CAA and impairment in episodic memory and executive function, suggesting that mood symptoms may contribute to cognitive difficulties in CAA. Greater depressive symptom severity was also associated with MRI markers of cortical and small-vessel brain injury. Because the study was cross-sectional, the findings do not establish whether CAA-related brain injury causes depression or whether depressive symptoms contribute to subsequent cognitive decline.
BACKGROUND: Cerebral amyloid angiopathy (CAA), a small-vessel disease characterized by β-amyloid deposition in cerebral vessel walls, is associated with cognitive impairment and dementia. Depression can independently affect memory and executive function, but the relationship between depressive symptoms, CAA-related brain injury, and cognition has been less clearly defined. This study examined whether depressive symptoms were associated with cognitive performance in people with CAA and whether depression helped explain the relationship between CAA and cognitive impairment.
DETAILS: Researchers analyzed baseline data from a prospective longitudinal cohort recruited through memory and stroke-prevention clinics at two Canadian centers. The analysis included adults aged ≥55 years with probable CAA and cognitively normal controls. Cognitive performance was evaluated across episodic memory, executive function, and processing speed, while depressive symptoms were assessed using the 15-item Geriatric Depression Scale (GDS-15). A score ≥5 was classified as "possible depression." The primary analysis included 168 participants: 85 with CAA and 83 cognitively normal controls. The mean age was 73.5 years among participants with CAA and 68.8 years among controls. Additional analyses exam-ined relationships between depressive symptoms and CAA-related MRI markers in 81 participants with CAA.
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Participants with CAA had substantially higher odds of possible depression than controls, with an odds ratio of 15.71 (95% CI, 4.26-80.05; P<0.001). Their GDS-15 scores were also 2.71 times higher than those of controls (95% CI, 2.10-3.51; P<0.001). Possible depression was associated with poorer performance across all three cognitive domains. After adjustment for age, sex, and education, associations were observed for episodic memory (β=-1.03; 95% CI, -1.53 to -0.53; P<0.001), executive function (β=-1.11; 95% CI, -1.65 to -0.58; P<0.001), and processing speed (β=-0.73; 95% CI, -1.24 to -0.21; P=0.006). Mediation analysis suggested that depressive symptoms accounted for 11% of the association between CAA and episodic memory and 9% of the association between CAA and executive function. No significant mediation was observed for processing speed, where depression accounted for approximately 2% of the association.
Among participants with CAA, greater depressive symptom severity was also associated with lower mean cortical thickness, cortical superficial siderosis, and a higher CAA-related small-vessel disease burden. Specifically, the count ratio was 1.33 (95% CI, 1.09-1.62; P=0.005) per SD decrease in cortical thickness, 2.04 (95% CI, 1.35-3.09; P<0.001) for cortical superficial siderosis, and 1.16 (95% CI, 1.00-1.35; P=0.047) for higher CAA small-vessel disease score.
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Source: Nukala, N., Muir, R. T., Beaudin, A. E., et al. Associations Between Cerebral Amyloid Angiopathy, Cognitive Impairment, and Depressive Symptoms. Neurology. 2026; 107(5): e218354. Published: September, 2026. DOI: 10.1212/WNL.0000000000218354.
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