Citations

Abstract Background Head and neck cancer represents the seventh most common cancer diagnosis globally. Maintaining sufficient nutrition is important for preventing malnutrition (undernutrition) and muscle wasting, which contribute to worse outcomes, although many patients are unable to maintain adequate oral intake throughout treatment. This guideline provides practice guidance on nutrition care for patients with head and neck cancer. Methods An interdisciplinary team developed key questions and scanned results from a systematic search of the PubMed, EMBASE, CINAHL, and Cochrane Central databases back to 2001. Recommendations were created for key questions concerning timing and duration of nutrition support (early vs delayed enteral nutrition [EN], postoperative feeding, and perioperative dietitian intervention), frequency of dietitian and speech pathology consultations, nutrition screening and assessment, macronutrient requirements, enteral access devices, adjunctive strategies (appetite stimulants and continuation of oral intake alongside EN), specialized nutrients (arginine, glutamine, ω‐3, and immunonutrition), and interdisciplinary care. Results Ninety‐two studies were included. Recommendations were made supporting early initiation of EN when oral intake is inadequate, nutrition within 24 h after surgery, weekly consultation with a dietitian during radiotherapy, malnutrition screening and assessment with validated tools, interdisciplinary models of care, dietitian involvement before and after surgery, and when to consider use of specialized nutrients. Recommendations are also provided for protein intake (1.2–1.5 g/kg/day) and energy intake (≥30 kcal/kg/day). Conclusion This guideline provides guidance for the nutrition care of patients with head and neck cancer, identifies research gaps, and calls for standardized outcome reporting to further the state of the evidence. This paper was approved by the ASPEN Board of Directors.

ABSTRACT Background Sunlight has profound impacts on physical and mental health, beyond vision, including effects on circadian rhythms, alertness, mood, and sleep. A family history of any mood disorders is strongly associated with psychiatric disorders including bipolar disorder. The purpose of this study was to evaluate the association between a family history of any mood disorder in patients with bipolar I disorder and solar insolation at varied international onset locations. Methods Data for this analysis were available from 5842 patients with a diagnosis of bipolar I disorder obtained at 83 collection sites in both hemispheres. This included 4752 patients from 71 collection sites in the northern hemisphere and 1090 patients from 12 collection sites in the southern hemisphere. Patient data variables were obtained from records or interviews. Solar insolation data were obtained from The National Aeronautics and Space Administration (NASA) Power database for each onset location, and the ratio of the mean monthly minimum/mean monthly maximum solar insolation was calculated. Typically, the ratio is largest near the equator (little yearly change in solar insolation) and smallest near the poles (large yearly change in solar insolation). Results A significant relationship was found between a family history of any mood disorder, the ratio of the mean monthly minimum/mean monthly maximum solar insolation, and gender. The odds of a family history of mood disorder increased as patient location nears the poles and decreased near the equator. Female gender also increased the odds of having a family history of a mood disorder. Conclusions This study highlighted the association between family history, solar insolation, and gender in international patients with bipolar I disorder. Given the profound effects of sunlight on human health, the family of patients with bipolar disorder who live in the same location with the same solar insolation, and especially females, may be at increased risk for a mood disorder.

Importance There is a need for greater recognition of clinical psychopharmacology endpoints, including instances where specific psychotropic medications may become unnecessary, redundant, contradictory, or otherwise inappropriate and therefore merit deprescribing. Objective To address circumstances warranting psychotropic medication deprescribing. Evidence Review The American Society of Clinical Psychopharmacology convened a panel of 45 international psychopharmacology experts who developed and completed a multiround Delphi survey and conducted a focused literature review between January and May of 2025, in order to identify areas of consensus or disagreement on key aspects of the deprescribing of psychotropic medications. These included collaborative risk-benefit assessments with patients; pharmacokinetic and pharmacodynamic factors; pharmacogenomics; distinguishing redundant or conflictual from complementary mechanisms of action; managing adverse effects; assuring medication adherence; drug tolerance or tachyphylaxis; medication misuse; and the psychological context and ramifications of deprescribing. Findings Consensus was achieved on 44 of 50 final Delphi statements (88%). Panelists unanimously agreed that components of a pharmacotherapy regimen should undergo periodic review to ensure that treatments target relevant symptoms and have favorable risk-benefit ratios. Key points of consensus were that deprescribing: (1) should not occur without first assessing medication adherence; (2) merits consideration if less than partial therapeutic response is apparent, or if treatment goals have been reached and relapse prevention is not a long-term objective; (3) involves psychological ramifications that warrant attention; (4) should be followed by close clinical monitoring; and (5) risk-benefit decisions should ideally involve active patient participation within a shared decision-making model. Conclusions and Relevance Through this Consensus Statement, the Task Force identified circumstances in which the selective elimination of certain psychotropic medications may be clinically indicated. Empirical trials are needed to assess the implementation of deprescribing protocols and gauge their safe, effective, and acceptable outcomes.

Abstract Background Penile inversion vaginoplasty (PIV) is a commonly performed gender-affirming procedure that requires postoperative dilation to maintain vaginal canal patency. Aim To characterize patient-reported dilation experiences and evaluate temporal trends in postoperative outcomes. Methods Consecutive patients undergoing primary PIV at a single center were prospectively surveyed at 1, 3, 6, 9, and 12 months postoperatively. Surveys were author-developed based on clinical experience and clinical review. Surveys assessed dilation frequency, session duration, depth achieved, and challenges encountered. Univariate analyzes were used to evaluate changes over time. Outcomes The primary outcome was the proportion of patients reporting any dilation-related challenge over time. Secondary outcomes included adherence metrics (frequency, days/week, session duration), depth achieved, and specific challenges. Results Seventeen of 27 patients completed all survey time points (63% response rate). On average, participants dilated 6.6 ± 1.4 days/week and 2.4 ± 0.9 times/day; sessions lasted 38.3 ± 16 minutes. Mean depth achieved was 4.05 ± 1.32 (13 cm standardized dilator set), with no significant decline over time. All patients reported at least one difficulty, most commonly tightness (71%), bleeding (71%), pain (65%), discharge (47%), and logistical barriers (24%). The prevalence of reported challenges declined significantly after six months (P < .05). Clinical Implications Early dilation-related difficulties are nearly universal and should be anticipated with proactive counseling and structured postoperative support, though symptoms improve over time. Strengths and Limitations This is the first prospective, longitudinal study of dilation following PIV, using an author-developed survey instrument to capture patient-reported outcomes. Limitations include modest sample size, potential response bias, and lack of assessment of challenge severity. Conclusion Reported dilation adherence following PIV is high, but most patients experience early challenges that diminish over time, highlighting the need for anticipatory counseling and individualized, symptom-responsive dilation protocols.

Abstract Aims Calcium release channel deficiency syndrome (CRCDS) results from loss-of-function (LOF) variants in the RYR2-encoded type 2 ryanodine receptor (RyR2), predisposing patients to sudden cardiac arrest/death (SCA/SCD) without abnormalities on a stress electrocardiogram (ECG). Undetected CRCDS may underlie idiopathic ventricular fibrillation (IVF) and sudden unexplained death in the young (SUDY). We aimed to determine the prevalence of potential CRCDS-causative RYR2 variants in IVF and SUDY. Methods and results We reviewed clinical evaluation and RYR2 genetic analysis of 169 IVF patients and 279 SUDY victims. Only ultra-rare (<0.005% in gnomAD) nonsynonymous RYR2 variants were considered potentially pathogenic. Among IVF patients, 6/169 (3%) overall—and 6/67 (9%) with exertion-related SCA—harboured an RYR2 variant and represent potential CRCDS cases. All exhibited normal resting and stress ECGs. Genetic analysis revealed six distinct RYR2 variants, two previously characterized as LOF. In SUDY, 31/279 victims (11%) had a RYR2 variant (30 unique variants), predominantly observed in exertion-related SCD 20/83 (24%) vs. rest-related 11/196 (6%). Of the 14 SUDY victims with functionally characterized RYR2 variants, five (2% of total cohort) had a LOF variant; among the 56 exertion-related SUDY cases, four (7%) had a LOF variant. Conclusion CRCDS may account for 3% of IVF overall and 9% of exertion-related SCA in IVF. Ultra-rare RYR2 variants may underlie up to 11% of SUDY, with 65% of RYR2-positive cases occurring during exertion. LOF-RYR2 variants may contribute to ≥7% of exercise-associated SUDY. Accurate identification of the underlying ryanodinopathy is essential for clinical management of affected patients.

Abstract Context Evidence on the etiology and function of adrenal masses in younger adults is scarce. Objective This work aimed to characterize the clinical, imaging, and biochemical presentation of adrenal masses in 18- to 40-year-olds. Methods A retrospective cohort study was conducted January 2016 to December 2021 at a tertiary academic medical center. Participants included young adults (age 18-40 years) with adrenal masses identified through radiologic registry. Exclusion criteria included preexisting adrenal masses before 2016, hyperplasia, or masses smaller than 1 cm. Outcomes included adrenal mass diagnosis, as determined by reference standard of histopathology, radiologic surveillance, and biochemical evaluation. Results A total of 255 patients (women 142 [56%]; White 156 [61%]; median age 35 years [interquartile range 30-39 years]) were included. Comorbidities included genetic predisposition syndromes (16, 6.3%), preexisting malignancy (70, 27%), obesity (100, 48%), hypertension (89, 35%), and diabetes (25, 10%). The majority of adrenal masses were incidentally found (184, 72%) and median size was 1.9 cm (IQR 1.4-2.7 cm) on detection. Among adrenal masses in young adults, prevalence of malignancy and pheochromocytoma was 16% and 4%, respectively; among adrenal incidentalomas, 5% were malignant. Factors associated with malignancy or pheochromocytoma in multivariable analysis included nonincidental mechanism of discovery (odds ratio [OR] 15.5; 95% CI, 7.2-35.7; P < .001), and larger size (OR 1.5; 95% CI, 1.2-2.0; P < .001). Hormonal evaluation was performed in only 57 (22%) patients and was positive for hormone hypersecretion in 16 (28%) of tested individuals. Conclusion We demonstrated a high prevalence of malignancy and pheochromocytoma in our cohort of young adults with adrenal masses. Completion of appropriate hormonal work-up was infrequent, potentially missing patients with functioning adrenal adenomas.

Abstract Objective: Suppressive antibiotic therapy (SAT) is used to prevent recurrent prosthetic joint infections (PJI) among patients who undergo debridement, antibiotics, and implant retention (DAIR). We aimed to assess SAT outcomes among younger, immunocompetent patients. Design: Retrospective cohort study. Patients: Immunocompetent patients <65 years of age who received DAIR for PJI of the hip, knee, or shoulder. Setting: Veterans Affairs hospitals. Methods: SAT was divided into short-term (oral antibiotics given for <3 months after guideline concordant therapy) and long-term SAT (>3 months to 5 years of oral antibiotics). The primary outcome was treatment failure (TF) and mortality combined. SAT was a time-dependent covariate in Cox proportional hazards models. Results: Of the 938 patients, 15% received short-term SAT, 20% received long-term SAT, and 65% did not receive SAT. Short- and long-term SAT were significantly associated with decreased hazards of TF or mortality (short-term SAT adjusted hazard ratio (aHR) = 0.27; 95% confidence interval (CI): 0.11, 0.67; Long-term SAT aHR = 0.52; 95% CI: 0.30, 0.89). Short-term SAT was significantly associated with C. difficile infection (aHR: 3.47; 95% CI: 1.38, 8.74). Short-term SAT (aHR: 7.83; 95% CI: 4.80, 12.77) and long-term SAT (aHR: 1.68; 95% CI: 1.19, 2.38) were significantly associated with antibiotic-associated diarrhea. Long-term SAT was not significantly associated with TF alone (aHR = 0.61; 95% CI: 0.32, 1.16). Conclusions: SAT was significantly associated with decreased death or TF and increased side effects. Benefits and risks must be weighed before prescribing SAT to younger, immunocompetent patients.

Background Immune checkpoint inhibitors (ICIs) improve survival in advanced non-small cell lung cancer (NSCLC), yet current biomarkers such as programmed death-ligand 1 (PD-L1) expression and response criteria (Response Evaluation Criteria in Solid Tumors, RECIST, V.1.1) align poorly with long-term survival. Radiomics has been proposed as a source of novel biomarkers, but standard radiomic approaches suffer from limited biological interpretability and poor generalizability across treatment settings. We address these gaps by developing the Quantitative Vessel Tortuosity (QVT) score, a biologically interpretable imaging biomarker that quantifies tumor vascular complexity—a known mediator of immune evasion—from routine imaging. We hypothesized that QVT score would improve prognostication and enable treatment response monitoring in ICI-treated NSCLC, independent of current biomarkers. Methods This retrospective, multicenter study analyzed 1,301 CT scans from 682 patients with ICI-treated NSCLC. An automated pipeline segmented lesions and tumor-associated vasculature within each scan, extracting 910 QVT features measuring vascular shape and complexity. Unsupervised clustering of these features in a discovery cohort (N=375) was performed to identify fundamental vascular phenotypes. A continuous QVT score was then derived using regularized logistic regression to map patients along this phenotypic spectrum. QVT score was externally validated in ICI monotherapy (N=172) and chemoimmunotherapy (N=135) cohorts. In a longitudinal cohort (n=143), early on-treatment QVT score changes were evaluated for overall survival (OS) association. Results Two robust vascular phenotypes emerged in the discovery cohort: a highly vascularized, chaotic “QVT High” phenotype with poor post-ICI OS and a “QVT Low” phenotype with normalized vasculature and improved ICI outcomes. The continuous QVT score was prognostic for ICI monotherapy (HR=1.17 per 0.1 increase, p=0.0028) and chemoimmunotherapy (HR = 1.23 per 0.1 increase, p = 4.9×10⁻⁵). High QVT status remained prognostic for both treatments after adjustment for PD-L1 and clinical variables (adjusted HR range: 2.13–2.38, p≤0.002). Early decreases in QVT score during therapy, indicating vascular normalization, were associated with improved OS (HR=1.93, p=0.0022) independent of RECIST best overall response and tumor volume change. Conclusions QVT score is a novel, biologically interpretable imaging biomarker that quantifies vascular complexity. It enables automated, non-invasive prediction and monitoring of ICI outcomes by capturing treatment-induced vascular remodeling. Integrating QVT score into clinical decision-making and drug development can address critical gaps in precision oncology.