Citations

BACKGROUND: Opioids prescribed for acute pain frequently remain unused, creating opportunities for unintended use, accidental ingestion, or diversion. Little is known about counseling patients receive from prescribers or pharmacists on storage and disposal of opioids. OBJECTIVE: To characterize clinician counseling on opioid disposal and patient-reported storage, use, and disposal practices among opioid-naive patients prescribed opioids for acute pain. DESIGN: Multicenter prospective cohort study with participant recruitment between September 2020 and March 2023. PARTICIPANTS: Opioid-naive patients prescribed opioids for acute pain in emergency departments, primary care or urgent care clinics, inpatient settings, and dental practices. MAIN MEASURES: Patient-reported receipt of counseling on the importance of opioid disposal and appropriate disposal methods; opioid storage practices; use and disposition of prescribed opioids; disposal methods; and reasons for keeping or disposing of leftover opioids. KEY RESULTS: Among 1708 participants, the median age was 38 years (IQR, 28-52); most were recruited from emergency departments (n=915; 53.6%) and primary care or urgent care clinics (n=307; 18.0%). Among 1233 participants who answered the question on counseling about the importance of opioid disposal, 811 (65.8%) reported receiving no counseling. Among 1220 participants who answered the question on counseling about appropriate disposal methods, 832 (68.2%) reported receiving no counseling. Among 812 participants who answered the question about storing opioids in a locked location, 610 (75.1%) reported never doing so. Among 929 participants providing information on opioid leftovers and disposition, 618 (66.5%) did not use all prescribed opioids. Among these 618 participants, 258 (42.8%) kept leftover opioids and 345 (57.2%) disposed of them. Among 256 participants who reported reasons for keeping leftover opioids, 159 (62.1%) wanted medication available for the same condition, 70 (27.3%) wanted medication available for a different condition, and 36 (14.1%) did not know how to properly dispose of the medication. CONCLUSIONS: Among opioid-naive patients prescribed opioids for acute pain, counseling about opioid disposal was uncommon, secure storage was infrequent, and leftover opioids were frequent, with many patients keeping leftover opioids for possible future use. These findings suggest opportunities to improve counseling on opioid storage and disposal and encourage safe disposal of unused opioids after acute pain treatment.

Chimeric antigen receptor T-cell (CAR-T) and CD20xCD3 bispecific antibody (BsAb) therapies are both effective for relapsed/refractory (R/R) follicular lymphoma (FL), but comparative real-world survival outcomes and time toxicity have not been characterized. We performed a multicenter retrospective study of 228 patients with R/R FL treated with standard-of-care CAR-T (n = 141) or BsAb (n = 87) across 17 U.S. academic centers in the third-line or later setting. Progression-free survival (PFS) and overall survival (OS) were stratified by 2 or ≥3 prior lines of therapy (LOT2 or LOT3+), including propensity matching. Time toxicity was measured by physical health care contact days. Median PFS was not reached (NR) with CAR-T and 581 days with BsAb in the LOT2 cohort (p < .0001), and was NR with CAR-T and 584 days with BsAb in the LOT3+ cohort (p = .0064). CAR-T recipients were younger (p < .0001) and had better performance status (p = .007) but were more refractory to prior LOT (p = .017). PFS advantages of CAR-T were independent of these differences. OS did not differ between treatment groups. CAR-T had significantly greater time toxicity over the first year, with higher mean contact days than BsAb in both the LOT2 (58 vs 44) and LOT3+ (69 vs 49) cohorts. In this large multicenter cohort of patients with R/R FL, CAR-T was associated with superior PFS but greater time toxicity compared with BsAb therapy. These findings provide real-world outcomes data and time toxicity benchmarks to support treatment sequencing decision-making in R/R FL.

ABSTRACT Background Pectus excavatum (PE), the most common congenital chest wall deformity, has known associations with connective tissue disorders and may lead to cardiopulmonary impairment; however, its relationship with atrial fibrillation (AF) remains underexplored. Objectives This study aimed to describe the frequency, clinical characteristics, and management of AF within an institutional cohort of patients with PE, and to determine whether the outcomes observed in clinically distinct subgroups persisted after adjustment for baseline risk. Methods This was a retrospective cohort study design. Patients with both PE and documented AF between January 1, 1990, and November 10, 2024, were included. Clinical, echocardiographic, and therapeutic data were collected. Bleeding and thromboembolic outcomes were evaluated using multivariable logistic regression adjusted for age, sex, CHA 2 DS 2 ‐VASc score, and anticoagulant class, and the surgically treated subgroup was additionally compared using propensity score matching. Results Among 11,578 patients with PE, 1309 (11.3%) had AF. Of those who had AF, mean age was 66.9 years; 54% were female, and 83% had paroxysmal AF. The mean CHA 2 DS 2 ‐VASc and HAS‐BLED scores were 2.8 and 1.9, respectively. Thromboembolic events occurred in 196 (15%) patients, most commonly stroke (11%), followed by pulmonary embolism (4%) and deep venous thrombosis (4%). Bleeding events occurred in 313 patients (24%), most commonly hematuria (12%), gastrointestinal bleed (11%), epistaxis (5%), and intracranial hemorrhage (1%). Seventy‐two patients (6%) underwent the Nuss procedure and were younger (45.3 vs. 68.2 years, p < 0.001), predominantly male (65%), and had lower risk scores compared to the non‐Nuss cohort. Patients who underwent the Nuss procedure had significantly fewer bleeding events (5.6% vs. 25%, p < 0.001) with similar thromboembolic rates. The pectus severity index, available in the 370 patients who underwent dedicated radiologic review, was not associated with bleeding (adjusted OR 0.89, 95% CI 0.75–1.05). The difference in bleeding by surgical status persisted after multivariable adjustment (adjusted OR 0.28, 95% CI 0.10–0.79) and after propensity score matching (5.6% vs. 16.7%, p = 0.030). Conclusions AF was identified in approximately one in nine patients within this single‐institution cohort of adults with PE, with paroxysmal AF representing the predominant subtype. Patients who had undergone surgical repair demonstrated a lower incidence of bleeding events than anticipated based on their baseline risk profile; however, given the limited number of events observed, this finding should be interpreted with caution and requires validation in larger studies. In the absence of a non–PE comparator group, these data are insufficient to determine whether PE independently confers an elevated risk of AF, and prospective, controlled investigations are necessary to elucidate this relationship.

Background: A growing body of research has connected electronic health record (EHR) workload to physician burnout. In orthopedic surgery, burn-out rates are rising. This study analyzed orthopedic surgeons' EHR use by sex and practice experience. Materials and Methods: EHR activity was analyzed among attending orthopedic surgeons at a single institution from May 2022 to May 2023. Demographic information included self-reported sex and practice years. Outcomes included time spent in notes, orders, clinical review, and in-basket daily; time spent outside of scheduled clinical responsibilities; volume of in-basket messages received daily; and proportion of orders with team contributions. Multivariable linear regression compared outcomes by sex and practice years. Results: A total of 105 orthopedic surgeons were included (91% male; mean 15.5 ± 9.8 practice years). Female surgeons logged 31% more time in the EHR overall (62.2 vs 47.4 minutes daily; P = .05) and on unscheduled days (10.1 additional daily minutes; P = .03), and received more messages from patients (2.4 vs 1.0 messages daily; P = .002) compared to male surgeons. Senior surgeons spent significantly less time on documentation and orders ( P ≤ .048) and on unscheduled days (3.3 less minutes daily per practice decade; P = .013), and had more support with placing orders ( P < .001). Conclusion: Female sex and fewer practice years were associated with increased EHR use. Female orthopedic surgeons tended to have higher patient message volumes, whereas junior surgeons tended to have less team support, spending more time on orders and documentation. Given known factors contributing to burnout, these findings warrant further investigation into targeted interventions to improve physician EHR use.

Purpose Neutropenic diet (ND) has historically been recommended to reduce infectious complications in patients with cancer. Although its use has declined over the past decade, recent studies, particularly in patients undergoing hematopoietic stem-cell transplantation (HSCT), have renewed concern regarding the safety of a liberalized diet (LD). We performed a meta-analysis of studies comparing ND with LD in patients with cancer. Methods We searched MEDLINE, Embase, and Cochrane databases from inception through January 2026. Comparative studies evaluating ND versus LD in adults or children with cancer were included. Primary outcomes were major infections and bacteremia/fungemia; secondary outcomes were pneumonia, diarrhea, and mortality. Random-effects meta-analyses were performed to calculate pooled relative risks (RRs) with 95% CIs. Results Fifteen studies including 4,320 patients met criteria for analysis. ND was not associated with significant differences in major infections (RR, 1.02 [95% CI, 0.88 to 1.18]; P = .795), bacteremia/fungemia (RR, 0.97 [95% CI, 0.78 to 1.22]; P = .805), pneumonia (RR, 0.98 [95% CI, 0.59 to 1.63]; P = .933), diarrhea (RR, 1.12 [95% CI, 0.96 to 1.31]; P = .159), or mortality (RR, 0.94 [95% CI, 0.77 to 1.15]; P = .632). Sensitivity analyses restricted to randomized controlled trials (RCTs) were consistent. In hematologic malignancy/HSCT studies (9 studies; 1,769 patients), no differences were observed across outcomes. In RCTs limited to these patients (6 studies; 855 patients), ND was associated with lower bacteremia/fungemia risk (RR, 0.67 [95% CI, 0.47 to 0.95]; P = .023), with no differences in other outcomes. Conclusion ND was not associated with reductions in major infections, pneumonia, diarrhea, or mortality compared with LD. These findings do not support routine implementation of ND for patients with short-term neutropenia or lower-risk cancer populations although selected high-risk patients, particularly those undergoing HSCT or experiencing prolonged neutropenia related to hematologic malignancies, may still warrant cautious dietary practices.

Abstract: Background Artificial intelligence (AI)-assisted colonoscopy reduces costs in colorectal cancer screening, but its incremental value relative to non-AI resect-and-discard (RD) strategies for diminutive polyps (≤ 5 mm) remain unclear. We aimed to compare the clinical, economic, and environmental outcomes of AI-assisted and non-AI RD strategies with standard of care (SoC). Methods In our Markov model simulating 6 million individuals aged ≥45 years undergoing screening colonoscopy, 4 strategies were evaluated: SoC, non-AI RD, CADe-assisted RD (CADe-RD), and CADe+CADx-assisted RD (CADe+CADx-RD). The primary outcome was total quality-adjusted life years (QALYs), with secondary outcomes including cost and carbon dioxide (CO₂) emissions. Results Non-AI RD achieved the lowest total cost ($36.6B) and carbon emissions (0.90 million kg CO₂), while yielding the highest QALYs (51.37 million), although differences in QALYs across strategies were small (<0.01%). CADe-RD and CADe+CADx-RD remained cost-saving relative to SoC ($36.9B and $37.4B vs $37.8B, respectively) but were associated with higher costs than non-AI RD. CADe modestly increased adenoma detection without improving QALYs, while the addition of CADx increased costs and emissions and resulted in slightly lower QALYs. Sensitivity analysis showed that CADe+CADx-RD matched or exceeded CADe-RD QALYs only within a limited region of high diagnostic performance. At currently reported CADx performance levels, CADe+CADx-RD yielded lower QALYs and higher costs than CADe-RD. CADe+CADx-RD achieved non-inferiority in QALYs relative to CADe-RD only within a limited region of high diagnostic performance. Conclusions In our non-deterministic model, non-AI RD provided the optimal balance of clinical benefit, cost savings, and lowest environmental impact.