United States

Background
Immune checkpoint inhibitors (ICI) are first-line treatments for many advanced solid tumors. Patients with type 2 diabetes mellitus (T2DM) have decreased response rates to ICI, and poor glycemic control is associated with worse outcomes in cancer patients. Further adjunctive therapies to enhance ICI efficacy are needed.

Sodium-glucose cotransporter-2 inhibitors (SGLT2i) have emerged as effective antihyperglycemic medications with concomitant cardiovascular benefits. SGLT2i are now approved in patients with T2DM and congestive heart failure (CHF). Pre-clinical studies suggest SGLT2i may help slow tumor growth in-vitro and in-vivo; however, there is a lack of clinical data regarding SGLT2i use in patients with advanced malignancy receiving ICI.

Methods
We performed a retrospective, matched cohort study of patients with stage IV malignancy and T2DM or CHF, who were treated with ICI using Epic Cosmos dataset (2013–2024). Ten solid tumor types, five ICI, and three SGLT2i were analyzed. Among 6,674 patients treated with ICI, 573 had at least one overlapping cycle of ICI and SGLT2i. 1:1 propensity score matching was conducted to balance baseline covariates, including cancer type, comorbidities, age at diagnosis, and sex. Kaplan-Meier curves were generated to examine survival differences, and Cox proportional hazards models were used to estimate hazard ratios (HR). The primary outcome was overall survival (OS) for the entire matched cohort and sub-groups by cancer, ICI, and SGLT2i types.

Results
Patients who received ICI and SGLT2i had significantly improved OS compared to those who received ICI alone (HR = 0.67, 95% CI: 0.57-0.78). Among cancer types, significant improvements in survival were observed in patients with renal cell carcinoma (RCC, HR = 0.58, 95% CI: 0.41–0.84) and non-small cell lung cancer (NSCLC, HR = 0.59, 95% CI: 0.42–0.84). Among ICI types, ipilimumab + nivolumab (HR = 0.50, 95% CI: 0.27-0.93) and pembrolizumab (HR = 0.58, 95% CI: 0.45-0.77) showed a significant improvement in survival when used with SGLT2i. There was no statistically significant difference in OS amongst the three SGLT2i types.

Conclusion
We observed encouraging improvements in OS in patients with T2DM or CHF receiving SGLT2i in addition to ICI across multiple solid tumor types. Patients with RCC and NSCLC derived the greatest benefit. Patients treated with either ipilimumab + nivolumab or pembrolizumab had the best responses to therapy. SGLT2i may be beneficial as adjunctive therapies in patients with advanced malignancy receiving ICI. Further prospective studies are needed to validate our observations and determine potential underlying mechanisms.


2025 AMA Research Challenge – Member Premier Access

Improved survival with sodium-glucose cotransporter-2 inhibitors and immune checkpoint inhibitors in metastatic solid tumors

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Hemodynamic responses to combined ice-cold water intake, leg raising, and the diving response in young healthy subjects – A potential intervention to convert paroxysmal atrial fibrillation.

Biola Eniola, Sukla Mohajan, Esmeralda Ponce, Gilda Tchao

Background: Patients with paroxysmal atrial fibrillation undergo electro-conversion approximately twice yearly, each requiring general anesthesia. In an attempt to reduce the number of required conversions, patients utilize self-management strategies including leg raising, autonomic maneuvers, and fluid/electrolyte intake. The effectiveness of such strategies is unknown. We explored the hemodynamic responses to these strategies in healthy participants.
Methods: The study was approved by the Institutional Review Board of Burrell College and all young healthy volunteers (n=15, 3♂) provided written informed consent. Exclusion criteria: Pregnancy/nursing; chronic or acute conditions; use of prescription medications except contraceptives. Some subjects participated in multiple sessions separated by at least two days. A 30-minute baseline recording (supine position) was followed by 10 minutes with legs raised by 20 cm (group 1); three inspiratory breath holds while wearing an ice-cold face mask (diving response, group 2); 30 minutes of recording following 500 mL ice-cold water imbibement (group 3); or a combination of these interventions (group 4). Stroke volume was obtained by impedance cardiography, heart rate was derived from the ECG, blood pressure was recorded by finger plethysmography. Data are presented as means±standard error of the mean. Statistics were calculated by one-way analysis of variance. 
Results: Systolic blood pressure increased with leg raising (121.9±4.0 mmHg at baseline vs. 139.4±7.2 mmHg, n=8, P=0.06), the diving response (121.9±3.0 mmHg at baseline vs. 136.1±5.0 mmHg, n=8, P=0.01), and ice-cold water imbibement (123.4±3.8 mmHg at baseline vs. 137.2±6.5 mmHg, n=8, P=0.03), but not for the combination of the three interventions (122.1±5.4mmHg at baseline vs.116.9±4.9mmHg, n=8, P= 0.16). Heart rate decreased in response to all interventions, with the most pronounced bradycardic response observed with the combination of the three interventions (68.8±3.5bmp at baseline vs 61.1±3.4bmp, n=8, P=0.01). The diving response increased stroke volume (68.6±6.6 mL at baseline vs. 94.4±10.2 mL, n=8, P=0.06) and cardiac output (4.2±0.4 L at baseline vs. 5.4±0.6 L, n=8, P=0.11). Likewise, the combination of all three interventions (group 4) increased stroke volume (59.1±6.8mL at baseline vs. 84.3±9.8 mL, n=8, P=0.01) and cardiac output (4.1±0.6 L at baseline vs. 5.2±0.7 L, n=8, P=0.03).
Conclusion: The combined application of ice-cold water imbibement, leg raising, and diving response elicited stronger hemodynamic responses than the individual interventions. The hemodynamic responses to the combined interventions are consistent with increased atrial stretch and cardiac autonomic modulation through baroreceptor and cardiopulmonary reflex responses. Whether these mechanisms can convert paroxysmal atrial fibrillation to sinus rhythm remains to be determined.

Hemodynamic Responses to Combined Ice-cold Water Intake, Leg Raising, and the Diving Response in Young Healthy Subjects – A Potential Intervention to Convert Paroxysmal Atrial Fibrillation.

Introduction
The purpose of this study is to examine return to recreation outcomes in patients following surgical treatment of malignant musculoskeletal tumors and identify which sports and activities to which patients are able to return.

Methods
On October 31st, 2024, a systematic review of the literature was conducted utilizing Pubmed, Cochrane, and Embase (OVID) databases. Abstracts and titles were screened by two independent reviewers for studies that investigated return to sport, activity, or recreation after a musculoskeletal tumor resection.

Results
Across 8 studies (6 case series, 1 cohort, 1 cross sectional), a total of 223 patients (119 males, 86 females) underwent surgical resection of a malignant musculoskeletal tumor and were considered in follow-up evaluations of physical activity. Of the 223 patients, 66% (147/223) participated in some level of recreational physical activity post-operatively. Eight patients over a total of two studies returned to sport at their competitive level, with competitive sports including soccer and dancing. Across 5 studies, the most common post-surgery sport was cycling (n=37, 12.5%). Average follow-up duration ranged from 85 days to 230 months. A variety of surgical techniques were utilized over the 8 studies, including intra-articular and extra-articular surgery, rotationplasty, arthrodesis, graft, and megaprosthesis.

Conclusion
While upper limb tumor resections may have better return to sport at a higher level of activity than lower limb tumor resections, overall return to sport at any level is approximately 66%. Post-surgery activity scale is lower than pre-surgery activity scale, with the most common sport after surgical resection becoming cycling. However, the lack of quality data in current literature makes it difficult to allow for evidence-based decision-making on return to sport after resection of malignant musculoskeletal tumors. Further studies are necessary to evaluate return to sport based on age, tumor diagnosis, surgery type, and pre and post-activity levels after both upper and lower extremity malignant musculoskeletal tumor resections.

Return to Recreation after Surgery for Malignant Musculoskeletal Tumors: A Systematic Review

Background:
Glucagon-like peptide-1 receptor agonists (GLP-1) are increasingly prescribed for diabetes and obesity, yet their long-term effects on bone health remain unclear. Clinical trials commonly report neutral or protective effects of GLP-1s on bone mineral density (BMD) but seldom consider dietary intake or nutritional status in their analysis. Given the appetite-suppressing effects of GLP-1s, users may have inadequate intake of nutrients essential for bone health. Consequently, findings from GLP-1 users with normal BMD may be misleading, as patients may still suffer from underlying nutrient deficiencies or reduced muscle strength, both of which contribute to future skeletal fragility. This study aimed to develop a more comprehensive profile of bone health in GLP-1 users by examining dietary intake, serum biomarkers, grip strength, and BMD.
Methods:
Data were obtained from the 1999-2020 National Health and Nutrition Examination Survey. Nutrient intake was assessed using 24-hour dietary recalls and compared to the recommended daily value (DV). Serum markers, including total calcium, phosphorus, and 25-hydroxyvitamin D, were analyzed to identify subclinical deficiencies. Muscular strength was assessed via handgrip dynamometry, stratified by age and sex, and categorized into percentiles based on population reference standards. Femur and lumbar spine dual-energy x-ray absorptiometry (DEXA) scans were used to assess BMD and evaluate associations with nutrient intake, serum biomarkers, and grip strength. 
Results
Among GLP-1 users (n=150), intake of bone supporting nutrients was suboptimal with vitamin D (18% of DV), vitamin E (47% of DV) and potassium (49% of DV) below recommended levels. Serum vitamin D deficiency (<20 ng/ml) was observed in 33% of users, 64% of whom were female. In grip strength analysis (n=29), 29% of female GLP-1 users were below the age-and sex-adjusted 20th percentile compared to 13% of males. Median lumbar spine BMD increased with age in males from 0.97 g/cm2 (IQR: 0.93-1.07 g/cm2 n=4) in 40-49 year olds to 1.21 g/cm2 (IQR: 1.19-1.27 g/cm2 n=9) in 60-69 year olds while remaining stable with age (range: 1.01–1.10 g/cm2) in females. 
Conclusion
This study developed a comprehensive profile of bone health in GLP-1 users, showing that despite increased BMD in males and stable BMD in females, many individuals, particularly women, had vitamin deficiencies, reduced grip strength, and other indicators of skeletal vulnerability. Patients on GLP-1s would likely benefit from more comprehensive monitoring of bone health, not only through traditional imaging studies, but also regular assessment of nutritional status, serum testing, and monitoring for functional status changes.


Multimodal Assessment of Bone Health in GLP-1 Agonist Users

Background
Effective prognostic communication is fundamental for informed, goal-concordant decision-making in critical illness. Prior research identified variability in how physicians convey prognosis, yet little is known about how that variability in language influences surrogate understanding. This study described physician prognostic language patterns and evaluated their impact on surrogate understanding.

Methods
This mixed-methods secondary analysis used data from a multicenter randomized clinical trial assessing a decision aid for surrogates of patients receiving prolonged mechanical ventilation (i.e., ≥ 10 days). Physician-estimated and surrogate-perceived one-year survival were measured on a 100-point scale before and after unstructured, audio-recorded, physician-surrogate meetings. We included cases with a ≥ 20-point discrepancy between physician estimate and surrogate perception of the physician estimate (i.e., “misunderstanding”) before the family meeting. The hybrid inductive-deductive codebook focused on physician prognostic language patterns, such as probabilistic and non-probabilistic language. Coders dual-coded
20% of physician-surrogate meeting transcripts in NVivo (Cohen’s kappa 0.89); remaining transcripts were single coded. Median percent coverage (MPC) describes the proportion of transcript content occupied by each code. Linear regression models evaluated associations between prognostic language patterns and change in misunderstanding, adjusting for baseline misunderstanding, health literacy, and study arm.

Results
Among 75 meetings with initial misunderstanding, pre-meeting physician prognostic estimates (mean 42.1; SD 26.7) were lower than surrogate perceptions (68.8; 30.1). Post-meeting, 57.3% of surrogates (n=43) demonstrated persistent misunderstanding. Prognostic communication occupied a median 23.3% of transcript content. Non-probabilistic language (MPC 18.6%) was more common than probabilistic language (5.2%). The most common sub-types were best- or worst-case scenarios (5.3%; e.g., "Best case, she walks again; worst case, she doesn't
improve"), general statements (3.2%; e.g., "His body’s still got a lot to fight through"), and opinions (3.0%; e.g., "I don’t think he’s gonna die here"). Numeric estimates were nearly absent (0.0%). Individual framing predominated (17.6%) over population-level statements (3.9%). Beta coefficients for modeled prognostic language patterns ranged from –0.74 to +0.90, with 95% confidence intervals overlapping zero in all cases. No prognostic language pattern was significantly associated with post-meeting understanding (p-values > 0.025 in bivariate analysis).

Conclusion
Surrogates in this cohort perceived physicians as more optimistic than they were, and most continued to misunderstand prognosis – suggesting current prognostic communication practices inadequately support comprehension. Physicians conveyed prognostic information in less than one-quarter of the conversation, using primarily individualized, non-probabilistic language. As no single behavior predicted understanding, further analysis of communication quality and variability within categories may inform strategies to improve clarity.

Prognostic Communication in Critical Illness: Language Patterns and Surrogate
Misunderstanding

Robotic Prostatectomy (RP) is the predominant surgical approach for localized prostate cancer in the United States and over 50% of RP are performed as ambulatory or same-day discharge encounters. Current literature supports that RP performed in the outpatient setting are as effective and have no increase in complications compared to those performed inpatient and cost nearly 20% less than those performed inpatient. However, in 2022, the Centers for Medicare and Medicaid Services (CMS) removed robot-assisted radical prostatectomies from the list of covered procedures for ambulatory surgery centers (ASC).

In 2021, an independent multi-specialty physician group performed RP in both a freestanding ASC and in an affiliated hospital. This study compares the clinical and pathological factors, operative metrics, and postoperative outcomes between RP performed by this physician group in an ASC and in a hospital.

This is a retrospective study of consecutive RP cases performed by two high-volume robotic surgeons at an ASC or a hospital between May 2021 and December 2021. Data on demographics (age, body mass index), clinical and pathological variables (prostate specific antigen, grade group, prostate volume, pathological stage), and operative metrics (American Society of Anesthesiologists (ASA) classification, estimated blood loss, operative time) were collected. Outcomes and complications were defined by recovery time, total length of stay, adverse events, and Clavien-Dindo classification. Analysis involved the use of descriptive statistics, t-tests for continuous variables, and Chi-Square analysis and Fisher’s tests for categorical variables.

40 ASC cases and 50 hospital cases were identified. There were no significant differences in mean age, BMI, PSA, prostate volume, and final pathological stage between groups. The hospital group had higher grade group classification. There were no significant differences in ASA classification, estimated blood loss, operative time, or complications between groups. 

RP performed in an ASC demonstrated outcomes comparable to those performed in a hospital. These findings are consistent with published evidence that outpatient RP are safe and cost- effective, supporting reconsideration of current CMS reimbursement policies that restrict access to ambulatory surgical care for prostate cancer.

Comparison of Same-Day Discharge Robotic-Assisted Radical Prostatectomy in Ambulatory Surgery Center vs. Hospital Setting

Introduction:

Myonecrosis is a rare but serious complication of diabetes, particularly in patients with end-stage kidney disease (ESKD), characterized by ischemic necrosis of skeletal muscles. Its diagnosis is often delayed due to overlapping presentations with cellulitis or deep vein thrombosis. Treatment is traditionally limited to supportive measures such as rest and pain control, which remains the cornerstone. The role of corticosteroids remains controversial in this condition as its effectiveness and utility is not widely understood. This case highlights the unconventional use of corticosteroids in managing refractory diabetic myonecrosis, emphasizing their potential in mitigating inflammation and promoting recovery.

Case Report:

We present a 31-year-old woman with ESKD on hemodialysis and a history of type 1 diabetes, who presented with recurrent, debilitating pain and swelling in the right lower extremity. Despite a comprehensive workup, including MRI and a muscle biopsy confirming myonecrosis, the patient’s symptoms persisted despite conventional supportive care. Following a multidisciplinary discussion, corticosteroid therapy was initiated, resulting in dramatic symptom resolution within 48 hours. The patient experienced significant pain reduction, improved mobility, and decreased swelling, allowing for discharge on a tapering steroid regimen. Notably, a subsequent recurrence of myonecrosis in a different muscle group also responded favorably to corticosteroid treatment, further underscoring its therapeutic potential in managing patients with this condition.

Discussion/Conclusion:

This case underscores the importance of considering corticosteroids as an adjunctive therapy in refractory diabetic myonecrosis, particularly in patients who fail to respond to standard care. A detailed workup, a high degree of suspicion, distinct clinical findings, and imaging such as MRI along with muscle biopsy can accurately diagnose this condition. While corticosteroids are not routinely used due to potential risks, their dramatic effect in this patient highlights the need for further research to better understand their role and refine treatment strategies. By expanding the therapeutic approach to diabetic myonecrosis, this case provides valuable insights for improving outcomes in this rare and challenging condition. This case opens the door for exploring corticosteroids as adjunctive therapy in similar diabetic patients with ESKD and refractory myonecrosis.

Steroids for Diabetic Myonecrosis in ESRD: An Unconventional Treatment with Unexpected Success

Background
The pelvic exam is used in the evaluation of many gynecologic complaints. Providers across all specialties should be able to perform this exam with an emphasis on consent, patient comfort, and accuracy. The OB/GYN clerkship is an important time for medical students to develop the technique and interpersonal skills necessary to perform pelvic exams on patients assigned female at birth. Graduating students should be able to independently perform these examinations accurately and sensitively; however, students report limited exposure in the clinical setting.
Methods
This was a prospective, mixed-methods study of medical students and OB/GYN preceptors at a large academic center in NYC between June 2024 and March 2025. The authors developed surveys using a modified Delphi process and refined them through cognitive interviews. Students logged the number of pelvic exams they performed and completed a survey at the end of the 5-week clerkship. Preceptors were surveyed via email. Quantitative analysis included descriptive statistics and nonparametric tests. Qualitative data from open-ended survey responses were analyzed inductively to identify key themes.
Results
Among 93 student respondents (91.2% response rate), the average number of exams performed per student was 4.25 speculum and 2.17 bimanual exams. Students at the academic center performed significantly fewer exams than those at the community hospital. Over half of students (51.6%) did not perform any bimanual exams. Cisgender male students performed fewer speculum exams than cisgender female students. Students reported increased confidence and reduced anxiety with pelvic exams after the clerkship. Simulation and gynecologic teaching associate sessions were rated as helpful, but students emphasized the need for real clinical opportunities. Among 89 preceptor respondents (52.0% response rate), barriers to student participation included patient preference, exam complexity, time constraints, and institutional climate. Preceptors at the academic center cited time constraints and institutional climate as barriers more often than those at the community hospital.
Conclusion
Despite improved confidence by the end of the OB/GYN clerkship, many students perform few pelvic exams in the clinical setting. Preceptor behavior, institutional policies, and clinical environment significantly impact student opportunity. To ensure all students meet pelvic exam learning objectives, institutions should supplement clinical training with simulation, improve preceptor engagement, and clearly communicate policies around student participation and patient consent.

Educational Experience & Ethical Tensions in Pelvic Exam Training: A Mixed-Methods Study

Background
Minority populations remain underrepresented in clinical trials due to multifactorial barriers, including restrictive eligibility criteria, systemic inequities, and patient-related factors. Although, culturally tailored, video-based educational interventions may help address these barriers, they remain understudied in thoracic oncology.
Methods
We developed 3 brief (<5 min), culturally tailored educational videos on clinical trials in thoracic oncology for Black (in English) and Hispanic/Latino patients (in English and Spanish). Eligible patients were adults (≥18 years) diagnosed with stage I–IV lung cancer, ECOG performance status of 0–2, self-identified as Black or Hispanic/Latino, proficient in English or Spanish, and had access to an electronic device. Patients completed pre-, immediate post-, and 6-month post-video surveys assessing knowledge, attitudes, and willingness to participate in clinical trials. Feasibility metrics included recruitment and survey completion rates, as well as video acceptability based on self-reported satisfaction. An exploratory aim was to assess clinical trial enrollment rates within 1 year of viewing the videos.
Results
Between April and September 2024, 54 patients were approached; 30 (56%) enrolled, 4 were deemed ineligible, and 20 declined participation. All enrolled participants completed both the pre- and immediate post-video surveys. Over 90% reported high satisfaction with the videos. Total knowledge scores increased significantly (p < .001), with specific gains in understanding pre-clinical studies (p = .012), placebo use (p = .001), and clinical trial registration (p = .012). Over 90% agreed that clinical trials are essential for drug development and improving lung cancer outcomes. However, 50% still reported potential barriers, including concerns about informed consent, randomization, cost, and provider communication. Willingness to participate in clinical trials increased significantly after viewing the videos (p = .04). At 6-month follow-up, 22 (73.3%) completed the survey; 2 (6.66%) participants had died. As part of our exploratory aim, within 1 year of the intervention, 8 patients (27%) enrolled in a therapeutic clinical trial (5 Black/African American; 3 Hispanic/Latino).
Conclusion
Our culturally tailored, patient-centered educational videos were feasible, well-received, and may have contributed to increased enrollment of minority patients in clinical trials. Broader implementation of these videos may enhance generalizability of findings and support more inclusive, evidence-based care as well as addressing disparities linked to the social construct of race.
Disclosures
Preliminary data presented at 2025 ASCO Annual Meeting as a poster (Abstract #1590); updated data presented here.

Updated Results from a Culturally Tailored Education Initiative to Enhance Clinical Trial Awareness in Thoracic Oncology

Assessing Patient Motivation for Requesting Safer Sex Kits in the Emergency Department: A Pilot Survey Study

Background
Condoms are an important public health resource to prevent sexually transmitted infections (STIs) and unwanted pregnancies. However, many barriers exist to access. Condom distribution programs (CDPs) are structural-level solutions that increase accessibility and availability of condoms in various settings. CDPs have increased condom use behaviors in diverse populations, including adolescents, sex workers, adults, and populations with high STI rates.

CDPs have been studied in outpatient and community settings, but there is limited data on their use in emergency departments (EDs). With increasing national rates of STI-related ED visits and increasing use of EDs for primary care, evaluation of safer sex resources in the ED is necessary. This pilot condom distribution survey study serves to close this gap in the research.

Our primary aim is to assess which patients are requesting safer sex kits and the relationship between sexual health risk factors and utilization. The secondary aim is to evaluate the University of Maryland ED as a potential condom distribution site for the Baltimore community.

Methods
ED staff provided safer sex kits consisting of condoms, STI education, and local resources by patient request from informational flyers. Each kit included the QR code to a brief anonymous survey. This questionnaire collected characteristics of patients who requested or received a kit in the ED. Participation was not a requirement for receiving the kits. 

Results
Ongoing distribution of the kits began on April 15, 2025. 31 responses to the survey have been received as of October 5, 2025. 43% were aged 18-25, 43% aged 26-35, and 13% aged 36-45. 57% identified as male and 3% non-binary/gender nonconforming. The most common reason reported for the ED visit was for STI/HIV testing (43%), 40% reported another reason, and 17% declined to answer. 30% of respondents reported using condoms approximately half the time when engaging in vaginal or anal sex. Barriers to condom use included decreased pleasure (30%), partner’s preference (27%), fit (10%), and other (17%). No respondents reported HIV, but 17% reported an STI diagnosed within the last year. Two respondents (7%) reported ever having sex in exchange for a place to stay, money, food, or other items

Conclusion
Preliminary findings suggest that safer sex kits in the ED can target young, sexually active individuals of all genders regardless of prior STI history. Although limited by sample size, initial results provide data on who is likely to access safer sex kits through the ED and suggest utility in considering the ED as another community CDP. Further research would need to be conducted to study this feasibility and impact as well as the pediatric ED as a CDP.

Assessing Patient Motivation for Requesting Safer Sex Kits in the Emergency Department: A Pilot Survey Study

Out-of-hospital cardiac arrest (OHCA) is a leading cause of preventable death, yet fewer than 40% of victims receive bystander CPR, with underserved communities facing the greatest barriers to access. Beat to Breathe CPR, a student-led nonprofit, implemented a mobile, outreach-based CPR program across New Jersey to improve community preparedness through free, one-hour training sessions tailored to specific audiences. In a pilot study of 15 youth camp counselors, average CPR confidence increased by 124% (p<0.001) and knowledge by 82% (p<0.001), with all participants reporting greater readiness to act during emergencies. These findings suggest that community-delivered, low-barrier CPR training can significantly improve layperson competence and confidence while reducing structural barriers such as cost and transportation. This model demonstrates a scalable approach to increasing CPR accessibility and preparedness among populations historically underrepresented in traditional CPR education.

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