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Abstract Background Chimeric antigen receptor T-cell (CAR-T) and bispecific antibody (BsAb) therapies are both effective for patients with relapsed/refractory (R/R) follicular lymphoma (FL), but differ in treatment schedules and associated “time toxicity,” or contact days spent physically interacting with the healthcare system. While contact days can be estimated from clinical trials, real-world data provides a more nuanced depiction of treatment-related time burden, which may guide treatment decision-making. The comparative time toxicity of CAR-T vs BsAb in R/R FL is not defined. Methods We conducted a multicenter retrospective study of adults with R/R grade 1-3A FL who received standard-of-care CAR-T (axi-cel, tisa-cel, liso-cel) or BsAb (mosunetuzumab, epcoritamab) in the third-line or later setting before Jan 1, 2025. Time toxicity was defined as outpatient or inpatient days with physical health care system contact, counting multiple visits on the same day as only one day. All days after treatment initiation were counted, regardless of disease progression, therapy completion, or relation to FL therapy. Median contact days over 1-year time horizon were compared, stratified by CAR-T vs BsAb, prior lines of therapy (LOT, 2 vs 3+), and time intervals (0-1, 1-3, 3-6, 6-9, and 9-12 months). Progression-free survival (PFS) and overall survival (OS) were calculated from day of CAR-T infusion or day 1, cycle 1 for BsAb. Cox regression and propensity matching (by age, ECOG, refractory to prior LOT, POD24) were used to assess predictors and survival associations with contact days. Results Among 209 patients from 15 U.S. academic centers, median age was 64, 37% were female, 61% received CAR-T (80% axi-cel, 7% liso-cel, 13% tisa-cel) and 39% BsAb (93% mosun, 7% epcor). Most had Grade 1-2 FL (72%), advanced stage (84%), and extranodal disease (51%). Median prior LOT was 3 (range 2-15), 41% were refractory to prior LOT, and 52% had POD24. Median number of BsAb doses was 10 (range 1-36). Patients receiving BsAb were significantly older (p<.01) and had higher CIRS comorbidity scores (p<.02) in both 2 and 3+ prior LOT cohorts, and had higher ECOG scores (p=.01) and were less likely to be refractory to prior LOT (p=.029) in 3+ LOT cohort. There were no differences in POD24 rates between CAR-T and BsAb. Median PFS for the entire cohort was 3.6 yrs; median OS was not reached. In the 2 prior LOT cohort (N=75), 60% received CAR-T and 40% BsAb. With median follow-up of 1.5 years, median PFS was not reached for CAR-T and 1.6 yrs for BsAb (p<.0001). In the 3+ prior LOT cohort (N=134), 62% received CAR-T and 38% BsAb. With median follow-up of 2 yrs, median PFS was 3.6 yrs for CAR-T and 1.6 yrs for BsAb (p=.0044). In propensity matched analysis, PFS was shorter for BsAb in both 2 LOT (HR 9.0, 95% CI 1.14-71.04, p=.037) and 3+ LOT (HR 3.25, 95% CI 1.06-9.97, p=.039) cohorts as compared to CAR-T. There were no significant differences in OS between CAR-T and BsAb. Median contact days were significantly higher for CAR-T vs BsAb in the 0-1 month interval: 19 vs 8 days in 2 LOT (p<.0001) and 18 vs 7 days in 3+ LOT (p<.0001) cohorts. There were no differences in contact days between CAR-T vs BsAb in subsequent time intervals. Over 1 year, CAR-T had significantly more time toxicity than BsAb: median 51 vs 36 contact days in 2 LOT (p<.0001) and 64 vs 38 days in 3L+ LOT (p<.0001) cohorts; these remained significant in the matched analysis. B symptoms (p=.04) and Grade ≥3 cytopenias (p=.007) were associated with higher contact days in 3+ LOT cohort in univariable analysis. Higher contact days were associated with inferior PFS (HR 1.01, 95% CI 1.00-1.02, p=.032) and OS (HR 1.01, 95% CI 1.00-1.02, p=.038) in 3+ LOT cohort regardless of treatment type. Discussion In this large real-world cohort of patients with R/R FL, CAR-T therapy resulted in better PFS but more time toxicity over the first year as compared to BsAb therapy. Excess time toxicity from CAR-T was driven by more contact days in the first month of treatment. This study provides benchmark data for counseling patients about expected time burden of CAR-T (51-64 days) and BsAb (36-38 days) over the first year of these therapies. Further, with superior PFS of CAR-T in this study and minimal impact of time toxicity on survival outcomes, these data can be used to better support shared decision-making in R/R FL by addressing patient preferences regarding both contact days as well as duration of disease control.

Introduction Hypoplastic left heart syndrome and Fontan procedure predispose to cardiac thrombus formation in the venous pathways due to the unique hemodynamic and hematologic disturbances inherent to the Fontan circulation. Systemic venous blood is routed passively to the pulmonary arteries without a subpulmonary pump, resulting in chronic low‐velocity flow, elevated central venous pressure, and venous stasis—all elements of Virchow's triad that favor clot formation 1 . Additionally, these patients exhibit reduced levels of protein C, coagulation factors II, V, VII, and X, plasminogen, and antithrombin III, along with increased levels of factor VIII 2,3 . Once a thrombotic event occurs, the rationale for lifelong anticoagulation is compelling. We report a case of an adult man that underwent Fontan palliation in infancy, with acute cerebral and renal infarcts, and discuss stroke and systemic embolism prevention. Case presentation A 22‐year‐old male with history of hypoplastic left heart syndrome status post Fontan procedure in infancy with congestive splenomegaly and liver disease presented with acute abdominal pain and was found to have bilateral renal infarcts. Anticoagulation was not initiated acutely and within 24 hours he developed left face and arm weakness, dysarthria and mild aphasia. Intravenous Tenecteplase was administered within 1 hour of symptom onset and was followed by symptoms’ complete resolution within 30 minutes of administration. Brain MRI confirmed scattered cerebral infarcts in the bilateral middle cerebral artery territories. Transthoracic echocardiogram showed atrial level shunting, expected due to fenestrated IVC to left atrium from prior Fontan procedure, and no evidence of atrial or ventricular thrombus. Due to the patient having evidence of multiple infarcts in multiple vascular beds within the brain and kidneys, an extensive hypercoagulable workup was undertaken which was unremarkable. The patient's stroke etiology was presumed to be cardioembolic from his altered cardiac anatomy with susceptibility to form venous thrombi and known surgically‐induced atrial level shunt. Low intensity heparin drip without bolus was started initially, and was transitioned to therapeutic apixaban upon discharge with proposed life long anticoagulation. Conclusions Subjects with hypoplastic heart syndrome display persistent unfavorable hemodynamics and procoagulant state after Fontan procedure. Either antiplatelet or anticoagulants are recommended after performing risk stratification. In high‐risk patients (recent thromboembolic event or stent, recurrent atrial arrhythmias, mechanical valve), therapeutic anticoagulation with either warfarin or direct oral anticoagulant is indicated, given increased vulnerability to recurrent events 1 . In intermediate‐risk subjects, antiplatelet or prophylactic doses of anticoagulation is indicated, whereas in low‐risk patients, antiplatelet agent is preferred.

Purpose: Despite the 2022 American Heart Association/American College of Cardiology guidelines recommending cardiac rehabilitation (CR) after aortic dissection repair, both patient participation in CR and the associated clinical outcomes remain poorly understood. Methods: Adults (≥18 years of age) discharged alive following thoracic aortic dissection surgery across the Mayo Clinic Enterprise (January 2012 to November 2022), with follow-up until May 2024, were included (IRB #24-001141). Data were presented using summary statistics and logistic regression modeling. Results: A total of 186 patients were referred; 37% were female, and the median age was 64 (51, 73) years. Dissections were classified as type A (43%), type B (18%), or a combination, and 55% had residual dissection. Over half (53%) did not start CR, with older age (aOR = 0.97: 95% CI, 0.94 - 0.99; P = .003), family history of aortic dissections and/or aneurysms (aOR = 0.17: 95% CI, 0.04 - 0.54; P = .005), and tobacco use (aOR = 0.35: 95% CI, 0.13 - 0.91; P = .037) being associated with lower odds of enrollment. Of the 87 who enrolled, 34 did so at a Mayo Clinic facility. There were no complications, with no difference in adverse outcomes. Among those with evaluations at graduation from CR (n = 21), quality of life (Dartmouth index 16 [14, 19] vs 25 [22, 30]; P = .002) and 6-minute walk distance (488 [375, 531] vs 302 [235, 398] m; P = .001) improved. Conclusions: Following thoracic aortic dissection repair, CR significantly improved quality of life and functional capacity without adverse events. Further work is needed to improve enrollment and establish data-driven safety margins for exercise.

Objective To assess the relationship in ratings of velopharyngeal closure between connected speech and sustained speech, as visualized on nasopharyngoscopy. Design Prospective observational study. Setting Craniofacial clinics in the United States and Canada. Participants Fifty-two participants with velopharyngeal insufficiency (VPI) who underwent nasopharyngoscopy and produced both connected speech and sustained speech of either /i/or /s/ during the procedure. Main outcome measure(s) Correlations and differences between connected speech and sustained speech for velopharyngeal closure percentage, velar movement, lateral pharyngeal wall movement, and velopharyngeal closure pattern. Results There were moderate to very strong correlations observed between connected speech and sustained /i/ for velopharyngeal closure percentage ( P < .01); extent of velar movement ( P < .01), and left ( P < .01) and right ( P < .01) lateral pharyngeal wall movement. Findings were similar between connected speech and sustained /s/. Differences between ratings made during connected and sustained speech were small: for velopharyngeal closure percentage, there was a 5% difference in the mean between connected speech and sustained /i/ (77.5% vs 72.5%) and a 7% difference for /s/ (79.3% vs 86.7%). Overall differences across ratings ranged from 2% to 12%. Closure pattern was rated the same for both connected speech and sustained /i/ in 90% of videos (n = 44/49; P = .38) and the same for connected speech and sustained /s/ in 95% of videos (n = 42/44; P = 1.00). Conclusions Ratings of velopharyngeal movement during nasopharyngoscopy are similar between connected speech and sustained /i/ and /s/ suggesting elicitation of only sustained /i/ and /s/ may be adequate in most cases when assessment of connected speech is not possible.

Abstract Introduction This is the first International Consultation on Sexual Medicine (ICSM) position paper on sexual health in older adults. Physical, cognitive, and psychosocial factors create a unique set of challenges related to sexuality in older adults. Objectives This study explores the impact of the physiological aspects of aging, state of health, psychological, relationship-related, and sociocultural factors, on sexual health in older adults. The goal of this review is to provide recommendations for the comprehensive evaluation and treatment of this population. Methods A narrative review was conducted under the auspices of the ICSM, as part of its ongoing efforts to develop expert, evidence-based guidance in the field of sexual health. A multidisciplinary panel of international experts composed of specialists in urology, gynecology, psychiatry, sexual medicine, social work, and sex therapy was convened. A comprehensive literature review was conducted based on a search of psychological sources (PsycInfo), medical databases (PubMed, Medline), and Google Scholar. All retrieved articles were reviewed and critically assessed. Recommendations were then formulated using a modified Delphi method. Results Although there is extensive literature on the prevalence and risk of sexual challenges of adults over the age of 65, there is limited evidence regarding the quality of treatment modalities. In particular, there is scant data on women in this age group. This population faces specific and multifactorial challenges, which point to the need for a comprehensive approach to their care. Conclusion Any approach to sexual health in older adults needs to take all the factors that affect sexual health into account, while endorsing the full spectrum of sexual expression in a non-judgmental way. Individuals in a relationship should be offered a couple-centered approach. Special attention is needed for individuals in cognitive decline. Healthcare providers must be aware of ageist biases, which may prevent them from providing appropriate care.

ABSTRACT Central venous catheters (CVCs) are a cornerstone of hematopoietic stem cell transplantation (HSCT), facilitating the delivery of chemotherapy, parenteral nutrition, medications, and blood products. Despite CVCs’ essential role, prolonged use can lead to complications such as increased risk of infection, thrombosis, mechanical issues, and psychosocial burden. However, the timing of CVC removal remains highly variable across institutions. Additionally, there are no standardized guidelines to balance the benefits of extended access against the risks of prolonged use. This narrative review examines the existing literature on CVC management post‐HSCT, highlighting key factors influencing the removal timing, such as patient characteristics, disease‐specific considerations, and institutional practices. The review emphasizes the urgent need for multi‐institutional research and standardized protocols to improve outcomes, reduce complications, and enhance the quality of care for HSCT patients.

Introduction Tobacco use is the most significant modifiable risk factor for adverse health outcomes, and early research indicates there are also significant harms associated with vaping. National targets aim to reduce smoking and vaping during pregnancy for Aboriginal and Torres Strait Islander people. While most Aboriginal and Torres Strait Islander people want to quit, cessation is frequently attempted without support, increasing the chance of relapse. Group-based smoking cessation programmes increase quit success by 50%–130% in the general population; however, they have never been evaluated in Aboriginal and/or Torres Strait Islander communities. Methods and analysis The Gulibaa study is an Indigenous-led and community-embedded project that will co-design, implement and evaluate a group-based model of care to support Aboriginal and Torres Strait Islander women to be smoke- and vape-free. Staff of Health Services in New South Wales, Australia, will receive training to deliver a face-to-face group-based smoking and vaping cessation intervention. Aboriginal and/or Torres Strait Islander people who identify as a woman or non-binary, are pregnant or of reproductive age (16 to 49 years), currently smoke or vape at least once per day and are willing to attend the programme are eligible to participate. Up to 500 participants will be recruited. A mixed method evaluation approach will be implemented guided by the RE-AIM framework. Outcomes will include intervention reach, intervention effectiveness (determined primarily by self-reported 7-day point prevalence abstinence at 6 months follow-up), acceptability and feasibility of the intervention, programme fidelity and maintenance and cost effectiveness. Ethics and dissemination Embedding culturally safe support to quit during pregnancy can result in improved outcomes for both mother and child and immediately improve intergenerational health and well-being. Ethics approval has been provided by the Aboriginal Health and Medical Research Council and the University of Newcastle. Study findings will be disseminated to Aboriginal and Torres Strait Islander communities in ways that are meaningful to them, as well as through Aboriginal health services, key national bodies, relevant state and federal government departments. Trial registration number ACTRN12625001050448.

ABSTRACT Objectives To review septal perforation management and outcomes in patients with hereditary hemorrhagic telangiectasia (HHT). Methods Collection and presentation of patient demographic, perforation size, and prior perforation and HHT treatment data over a 20‐year period. Symptom and quality of life treatment outcomes were determined using the Nasal Obstruction Symptom Evaluation (NOSE)‐Perf scale and the 5‐Factor Glasgow Inventory (GBI‐5F), respectively, in patients treated since 2017. Results Nine patients met study criteria. Mean (range) age was 64.4 (52–80) years and seven were biological males. Mean (range) perforation length and height were 1.9 (1.2–2.6) and 1.4 (1.0–1.8) cm. Four patients were treated with a customized septal button, one with posterior septal resection, and four with endonasal bilateral mucosal flap repair supported with an interposition graft. The button prostheses were well tolerated and the surgical closures successful at 8–60 months postoperatively. Subjective responses in the first three patients, and NOSE‐Perf with GBI‐5F scores in the latter six patients, demonstrated symptom and quality of life improvement for all patients. Perforation repair patients demonstrated substantial improvement in mean GBI‐5F subdomain scores for quality of life, self‐confidence, and social involvement and all have undergone sodium tetradecyl sclerotherapy injection postoperatively without re‐perforation. Conclusion Symptom and quality of life improvement can be achieved in HHT patients with a perforation using customized septal buttons, posterior septal resection, or bilateral flap surgical repair. Surgical closure combined with injection sclerotherapy is feasible with a low risk of re‐perforation and represents an effective treatment strategy in selected patients. Level of Evidence 4.

Purpose: The purpose of this study was to compare the height of velopharyngeal (VP) closure in relation to the palatal plane between individuals with velopharyngeal insufficiency (VPI) with or without cleft palate and individuals without cleft palate and with normal speech, considering the effects of age and sex. Method: Magnetic resonance imaging was used to analyze the height of VP closure in the midsagittal view during phonation of /i/ and /s/ sounds among 105 individuals with VPI and 45 individuals without cleft palate and normal speech. Results: Independent-samples t tests demonstrated that individuals with VPI display a significantly lower mean height of VP closure (3.7 mm) compared to individuals without cleft palate and normal speech during phonation of /i/ and /s/ sounds ( p < .001). Analysis of variance was used to evaluate the impact of age and sex on the height of VP closure. Significant differences were observed between the height of VP closure in individuals with VPI and those without cleft palate and normal speech across the age span during the production of /i/ and /s/ sounds. However, nonsignificant differences were found between the height of VP closure in males and females of the VPI group and those without cleft palate and normal speech during the production of these sounds. Conclusions: The results revealed the variations of the height of VP closure in relation to the palatal plane. These findings provide insights into the presurgical planning for individuals with VPI undergoing palatal surgeries, especially the location of pharyngeal flap insertion.