Citations

Abstract Appropriate short-term use of opioids in opioid-naive adults can result in unintended prolonged opioid use (UPOU) which is associated with significant morbidity and mortality. The objective of this prospective case–control study was to identify incident cases of UPOU and to compare their characteristics with patients who did not progress to UPOU. Opioid-naive adults receiving an initial opioid prescription for surgical or nonsurgical indications were recruited at 3 clinical sites. Patients progressing to UPOU (cases) were identified 90 days after the initial prescription and compared with patients who did not progress to UPOU (controls). The status of opioid use was verified using urine drug tests. The cohort included 513 cases and 517 controls. The mean (SD) patient age was 49.6 (15.3) years and 694 (67.4%) were female. In an adjusted logistic regression analysis, several patient characteristics significantly associated with UPOU included ≥2 emergency department evaluations in the past year; prior spine, joint replacement, or cataract surgery; status as a current or former smoker; daily use of over-the-counter pain medications; opioid craving; and greater pain interference. Conversely, characteristics negatively associated with UPOU included postsurgical pain as the indication for the initial opioid prescription, prior pregnancy, greater widespread body pain, and lower levels of general activity. The findings of this study offer novel insights into the behavioral pain responses and patient characteristics associated with UPOU. These results will be used to promote strategies to identify at-risk patients and to deploy interventions targeting the modifiable risk factors for UPOU.

Background: Reoperative metabolic and bariatric surgery (MBS), consisting of revision and conversion surgery, carries higher morbidity and mortality compared with primary procedures, yet robust long-term data are limited. Methods: A retrospective review was conducted of all patients 18 years of age or older who underwent first-time reoperative MBS between 2000 and 2024 at a single large quaternary referral center. Data were stored securely and analyzed in R (v4.4.2) using standard descriptive statistics and group tests ( t tests/Wilcoxon/Kruskal-Wallis; χ²/Fisher). Sparse late-complication data precluded pairwise tests. Results: Three hundred sixty patients, 86% female, mean age 50 years, underwent reoperative MBS. Conversion to Roux-en-Y gastric bypass (49%) was the most common surgery. The majority were performed for weight recidivism (37%). Length of stay, estimated blood loss, length of surgery, complication rates, readmission rates, and reintervention rates varied by type of reoperative MBS performed and indication. Most early complications were Clavien-Dindo 2, and most late complications were Clavien-Dindo 3b for all approaches. There was one procedure-related death in the study following an open conversion. Conclusion: In this 24-year single-center cohort, weight recidivism was the most frequent indication for reoperation and was associated with improved perioperative outcomes and durable long-term weight loss. As the landscape of bariatric surgery continues to evolve, we recommend early referral to centers with reoperative MBS expertise.

BACKGROUND: Patients with locally advanced rectal cancer face substantial costs related to multimodal therapy. However, the extent of this burden is poorly characterized. OBJECTIVE: To characterize the prevalence and predictors of patient-reported financial toxicity after treatment for locally advanced rectal cancer. DESIGN: Multicenter retrospective cohort study with a cross-sectional survey administered to assess patients’ financial concerns as well as clinicodemographic data. SETTING: Three high-volume tertiary academic centers. PATIENTS: Patients who completed treatment for pathological stage II to III rectal adenocarcinoma between 2000 and 2019 and were alive. MAIN OUTCOME MEASURES: Patient-reported financial toxicity and risk factors associated with financial toxicity. RESULTS: A total of 523 patients were identified, 190 (36.3%) responded to the survey, and 2 were excluded for incomplete surveys. Of the responders, 163 (86.7%) were identified as having financial toxicity related to their cancer diagnosis, and most (96.8%) had insurance. Patients with financial toxicity were less likely to have fully paid medical leave (39.8% vs 75%; p = 0.03) compared to patients without financial toxicity. They also reported increased difficulty paying bills ( p < 0.001) and decreased monthly household income ( p < 0.001) due to their diagnosis. Furthermore, these patients reported increased difficulty paying for transportation to medical appointments ( p = 0.002) and were less likely to be completely satisfied with their insurance coverage ( p = 0.003). Feeling well informed regarding treatment-related costs was associated with decreased odds of financial toxicity (OR 0.14; 95% CI, 0.02–0.78; p = 0.02), whereas taking unpaid leave for treatment was associated with increased odds of financial toxicity (OR 4.71; 95% CI, 1.36–16.34; p = 0.01). LIMITATIONS: Cross-sectional design and moderate response rate may introduce selection and recall bias. CONCLUSIONS: Patients undergoing treatment for locally advanced rectal cancer, including those insured, are at risk for financial toxicity due to direct and indirect costs. Effective communication between these patients and physicians regarding the economic implications of treatment is essential to reducing financial toxicity. See Video Abstract . TOXICIDAD FINANCIERA TRAS EL TRATAMIENTO DEL CÁNCER RECTAL LOCALMENTE AVANZADO ANTECEDENTES: Los pacientes con cáncer de recto localmente avanzado enfrentan costos sustanciales relacionados con la terapia multimodal. Sin embargo, la magnitud de esta carga está poco caracterizada. OBJETIVO: Caracterizar la prevalencia y los predictores de la toxicidad financiera reportada por los pacientes después del tratamiento para el cáncer de recto localmente avanzado. DISEÑO: Estudio de cohorte retrospectivo multicéntrico con una encuesta transversal para evaluar las preocupaciones financieras de los pacientes, así como datos clínico-demográficos. ESCENARIO: Tres centros académicos terciarios de alto volumen. PACIENTES: Pacientes que completaron el tratamiento para el adenocarcinoma de recto en estadio patológico II-III entre 2000 y 2019 y estaban vivos. PRINCIPALES MEDIDAS DE RESULTADOS: Toxicidad financiera reportada por los pacientes y factores de riesgo asociados con la toxicidad financiera. RESULTADOS: Se identificó a un total de 523 pacientes, 190 (36,3%) respondieron a la encuesta y 2 fueron excluidos por encuestas incompletas. De los encuestados, 163 (86,7 %) presentaron toxicidad financiera relacionada con su diagnóstico de cáncer, y la mayoría (96,8 %) contaba con seguro médico. Los pacientes con toxicidad financiera tuvieron menos probabilidades de tener licencia médica con goce de sueldo completo (39,8 % frente a 75 %; p = 0,03) en comparación con los pacientes sin toxicidad financiera. También informaron mayor dificultad para pagar facturas ( p < 0,001) y una disminución de los ingresos familiares mensuales ( p < 0,001) debido a su diagnóstico. Además, estos pacientes informaron mayor dificultad para pagar el transporte a las citas médicas ( p = 0,002) y menor probabilidad de estar completamente satisfechos con su cobertura médica ( p = 0,003). Sentirse bien informado sobre los costos relacionados con el tratamiento se asoció con una menor probabilidad de toxicidad financiera (OR: 0,14; IC del 95 %: 0,02-0,78; p = 0,02), mientras que tomar una licencia sin sueldo para el tratamiento se asoció con una mayor probabilidad de toxicidad financiera (OR: 4,71; IC del 95 %: 1,36-16,34; p = 0,01). LIMITACIONES: El diseño transversal y la tasa de respuesta moderada pueden introducir sesgos de selección y de recuerdo. CONCLUSIONES: Los pacientes en tratamiento para el cáncer de recto localmente avanzado, incluidos los asegurados, corren el riesgo de sufrir toxicidad financiera debido a los costos directos e indirectos. Una comunicación eficaz entre estos pacientes y los médicos sobre las implicaciones económicas del tratamiento es esencial para reducir la toxicidad financiera. ( AI-generated translation )

Most falls occur while walking, making gait quality a logical therapeutic target. Many temporo-spatial variables have been implicated in increased fall risk, but these are dependent upon kinematic parameters of the joints involved in the gait cycle. The widespread availability of wearable sensors has made the acquisition of kinematic data feasible, and those related to the ankle are most relevant, as they relate most closely to causes of falls, trips, slips, and mis-steps. The purpose of this study is to estimate the extent to which measures of ankle angular velocity (AV) during walking are associated with falls. This is a comparative study of ankle AV metrics between people who have or have not experienced a fall in the past year. Data came from experimental use of the Heel2Toe™ sensor in a variety of settings, including demonstrations and clinical research studies. The sample comprised 387 participants, of whom 68 (17.6%) self-reported falling in the past year. Logistic regression with a natural cubic spline with 3 degrees of freedom identified AV of the angle at heel strike to discriminate between fallers and non-fallers, and the regression parameters were used to propose an algorithm to estimate fall risk. Applying the algorithm to the existing data yielded a range of probabilities from 0.0480 to 0.7245 depending on age of the person assessed. Further testing of this algorithm in different samples is warranted.

ABSTRACT Background Diabetic ketoacidosis (DKA) is a severe diabetes complication managed with fluids, insulin and electrolyte correction. This review evaluates the debated effectiveness of bicarbonate therapy on DKA outcomes. Methods Following PRISMA guidelines, we systematically reviewed studies on bicarbonate therapy in DKA. We searched PubMed, Google Scholar, the Cochrane Library and ClinicalTrials.gov (as of August 2024), including studies on patients with DKA. Meta‐analysis was conducted using RevMan. Bias risk was assessed with the Newcastle‐Ottawa Scale (NOS) for cohort studies, Cochrane's ROB‐2 for RCTs and the Joanna Briggs Institute (JBI) Scale for case series. Prospero ID: CRD42024581810. Results Eight studies, including 646 patients, met the inclusion criteria. Participants' mean ages spanned from approximately 9.7 years to 45.8 years. Bicarbonate therapy did not significantly improve pH levels (mean difference = −0.02, 95% CI [−0.13, 0.09], p = 0.7), time to resolution of acidosis (mean difference = 0.09 h, 95% CI [−2.6, 2.79], p = 0.95) or potassium levels (mean difference = −0.10, 95% CI [−0.49, 0.29], p = 0.61). Bicarbonate therapy was associated with a marginally longer duration of hospital stay (mean difference = 13.63 h, 95% CI [0.23, 27.03], p = 0.05), although the overall effect size was small. No significant difference was observed in the incidence of hypoglycemia (odds ratio = 2.62, 95% CI [0.59, 11.63], p = 0.20). High heterogeneity was observed across most outcomes, mainly due to variability in study protocols and patient populations. Conclusion Bicarbonate therapy provided no meaningful clinical benefit in the routine management of DKA and was associated with potential harm, including worsened hyperglycemia. Consistent with current guidelines, its use should be restricted to cases of severe acidemia (pH < 6.9). Further high‐quality studies are needed to clarify its role in extreme acidosis and to explore alternative buffering strategies.

While the clinical focus on the sentinel lymph node biopsy (SLNB) is the presence of intra- or extra-nodal metastases, preclinical studies suggest that tumor-draining SLNB-associated vascular architecture and adhesion properties are altered regardless of SLNB positivity. Human intravital microscopy (HIVM) has defined blood vessel abnormalities that may impact lymphocyte adhesion and systemic drug delivery at primary melanoma sites. In this pilot study of HIVM during melanoma SLNB, we sought to determine the feasibility of obtaining HIVM observations of SLNB-associated vessels. We successfully performed HIVM in all 20 SLNB patients, and 7 were found to have nodal micrometastases by standard pathology. HIVM was capable of identifying both functional and non-functional SLNB-associated vessels based on the presence or absence of fluorescent dye uptake, respectively. Comparing vessel characteristics as a secondary exploratory objective, no statistically significant differences were noted in the diameter, flow rate, functionality, or shear stress of SLNB-associated blood vessels between positive and negative SLNBs, which may likely have been a reflection of the minimal disease burden. Nonetheless, these initial observations provide the framework to optimize future trials of HIVM in cancer patients.

Objective Diffuse alveolar hemorrhage (DAH) is a life‐threatening presentation of antineutrophil cytoplasmic antibody–associated vasculitis (AAV). Patients with AAV are at an increased risk of venous thromboembolic events (VTEs). These manifestations can co‐occur; however, the prognosis and management of these patients are poorly understood. Methods In this retrospective observational study, we included patients diagnosed with AAV who presented with both DAH and VTE during the same outpatient visit or in the same inpatient treatment episode. Results Among 121 patients with proven DAH secondary to AAV managed at our institution, 14 (11.6%) were also diagnosed with VTE. Patients were predominantly men (71%) with median age at diagnosis of 67 (interquartile range 56–72) years. Five patients were diagnosed with DAH followed by VTE, four patients were diagnosed with VTE before developing DAH (T‐AAV), and five patients were diagnosed with VTE and DAH simultaneously (HT‐AAV). Inferior vena cava filters were placed in 13 patients (93%). Although most patients received systemic anticoagulation within 30 days of DAH diagnosis, anticoagulation management was individualized based on clinical presentation. One patient with preexisting interstitial lung disease died of respiratory failure after initially presenting with pulmonary embolism and later developing DAH during hospitalization. Bleeding complications, including recurrent DAH or retroperitoneal hematoma, were observed in six patients (43%). Three patients (21%) experienced progression or recurrence of VTE within 90 days. Conclusion Management of patients with DAH and VTE is challenging and should be guided by the severity of DAH, additional organ manifestations of AAV, and risk stratification of the presenting VTE.