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Objectives: Prior studies report lower return to preinjury level of sport in patients who undergo bilateral anterior cruciate ligament (ACL) reconstructions compared to unilateral reconstructions, with the most common cited reason being fear of reinjury. The purpose of our investigation was to compare subsequent return rates and psychological readiness to return to sport (RTS) in patients who underwent bilateral versus unilateral ACL reconstructions. Methods: A retrospective review of patients who underwent ACL reconstruction at a single academic institution between 2012-2021 with a minimum of 1-year follow-up was conducted. Patients were divided into bilateral and unilateral cohorts. Those who underwent bilateral ACL reconstruction were matched 1:3 to unilateral reconstruction based on age, sex, BMI, and primary sport. Primary outcomes included return to sport, level of RTS and psychological readiness to RTS, assessed by the validated ACL- Return to Sport after Injury (ACL-RSI) scale. Within the ACL-RSI questionnaire, fear and confidence to return to sport were specifically analyzed. Fear to RTS was measured on a scale of 0-100 with 0 equal to extremely fearful and 100 equal to no fear at all. Confidence to RTS was measured on a scale of 0-100 with 0 equal to not at all confidence and 100 equal to fully confident. Statistical analysis was performed in R studio, with chi-square used for categorical values and two-sided t-test for continuous. Results: One hundred eighty-one patients were included, forty-three bilateral ACL reconstructions and one hundred thirty-eight unilateral. The unilateral cohort included 69 (50.0%) males and 69 (50.0%) females and the bilateral cohort included 22 (51.2%) males and 21 (48.8%) females. Mean age was 26.0 (14-56) in the unilateral cohort and 25.2 (14-50) in the bilateral cohort. Mean BMI was 25 (15.3-39.2) in the unilateral cohort and 28 (15.1-39.7[SM1] ) in the bilateral cohorts (p=.08). The percentage of individuals who returned to sport in the bilateral reconstruction cohort was not significantly different from those who returned in the unilateral cohort (79.6% vs 76.7%, p=0.85). There was no significant difference in psychological readiness to RTS (mean score 52.6 for bilateral and 47.4 for unilateral, p=0.31). There was also no significant difference between the level at which bilateral versus unilateral patients returned to sport. 59.6% unilateral returned to the same or higher level and 60.6% bilateral returned to the same or higher level, p=0.92. There was no significant difference in the reported scale of psychological readiness to return to sport (52.6 for bilateral and 47.4 for unilateral, p=0.31). When asked about fear to RTS, the mean scale response was 42.2 in the unilateral cohort and 46.5 in the bilateral (p=0.45). Conclusions: There is no difference in RTS and level of sport returned to between patients who undergo bilateral ACL reconstructions compared to patients who undergo unilateral ACL reconstructions. Psychological readiness, fear and confidence to return to sport were not different between unilateral and bilateral injuries.

Every doctor soon gets a clear sense of what the public's first impression of them is; we learn to accept it, adapt to it as an advantage, and use the anecdotes it creates for dinner conversation.

Cronbach’s alpha is one of the most widely used measures of reliability in the social and organizational sciences. Current practice is to report the sample value of Cronbach’s alpha reliability, but a confidence interval for the population reliability value also should be reported. The traditional confidence interval for the population value of Cronbach’s alpha makes an unnecessarily restrictive assumption that the multiple measurements have equal variances and equal covariances. We propose a confidence interval that does not require equal variances or equal covariances. The results of a simulation study demonstrated that the proposed method performed better than alternative methods. We also present some sample size formulas that approximate the sample size requirements for desired power or desired confidence interval precision. R functions are provided that can be used to implement the proposed confidence interval and sample size methods.

This article describes conceptual advances of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) working group guidance to evaluate the certainty of evidence (confidence in evidence, quality of evidence) from network meta-analysis (NMA). Application of the original GRADE guidance, published in 2014, in a number of NMAs has resulted in advances that strengthen its conceptual basis and make the process more efficient. This guidance will be useful for systematic review authors who aim to assess the certainty of all pairwise comparisons from an NMA and who are familiar with the basic concepts of NMA and the traditional GRADE approach for pairwise meta-analysis. Two principles of the original GRADE NMA guidance are that we need to rate the certainty of the evidence for each pairwise comparison within a network separately and that in doing so we need to consider both the direct and indirect evidence. We present, discuss, and illustrate four conceptual advances: (1) consideration of imprecision is not necessary when rating the direct and indirect estimates to inform the rating of NMA estimates, (2) there is no need to rate the indirect evidence when the certainty of the direct evidence is high and the contribution of the direct evidence to the network estimate is at least as great as that of the indirect evidence, (3) we should not trust a statistical test of global incoherence of the network to assess incoherence at the pairwise comparison level, and (4) in the presence of incoherence between direct and indirect evidence, the certainty of the evidence of each estimate can help decide which estimate to believe. •The application of the Grading of Recommendations Assessments, Development, and Evaluation approach to a number of network meta-analyses in the 3 years since the original guidance publication has led to advances that have strengthened the conceptual basis.•We present, discuss, and illustrate four conceptual advances. These are based on two principles: we need to rate the certainty of the evidence of each pairwise comparison within a network separately and that we need to consider both the direct and indirect evidence contributing to each network estimate.•Although maximizing the efficiency of the process is desirable, as illustrated in the conceptual advances, use of these strategies requires careful judgment.

BACKGROUND:Prior authorization (PA) poses a burden to HCPs and their staffs when prescribing biologic therapy for patients with IBD. Our aim was to determine the effectiveness of 3 CME activities on clinician knowledge, confidence, and performance related to PA processes and success rates for biologic therapy.METHODS:Outcomes measurements were taken directly before (n ≥ 241) and after the activities (n ≥ 229), as well as 3-months after activity completion. This 3-month follow-up sample (n = 30) was matched at the same time to a control sample of clinicians who did not participate in the education (n = 30).RESULTS:4,840 learners completed the 3 modules, including 1,195 downloads of the podcast version. Key knowledge improvements were shown in helping patients with medication co-pays, use of specialty pharmacists, standardizing EHR clinical documentation of patients with IBD, requesting peer-to-peer review, and expediting submissions with the use of templates. Prior to participation, confidence in the current processes to manage prior authorizations was low. Three months following education, nearly all clinicians surveyed indicated that they were “confident” or “extremely confident” in these elements of care. Comparative analysis shows a large effect when comparing the educational learners pre- vs. post-activity (Cohen’s d = 1.37) and pre- vs. 3 –month follow-up (d = 0.55). However, comparing post-participation vs. a non-participant control is smaller (d = 0.20, 15%). This shows that our particular educational learners were coming at this program with more knowledge and practice gaps in the pre-authorization process than the general clinician population. Predictive modeling utilized a regression analysis showed increasing confidence in the use of AGA Care Pathways will significantly increase documentation of pertinent lab results and imaging related to IBD and significantly increase use of a template.CONCLUSION(S):This program achieved large reach with education targeted specifically to those clinicians who needed it most. The education increase clinician knowledge and confidence in the use of this knowledge to acquire prior authorization for biologics. For future PA initiatives, learners may benefit from a mock review of a PA request to best explain individual elements of the decision-making process.