Nevin Manimala

Nurs Educ Perspect. 2026 Aug 3. doi: 10.1097/01.NEP.0000000000001587. Online ahead of print.

ABSTRACT

AIM: The purpose of this study was to examine the relationship between undergraduate nursing student burnout and faculty immediacy behaviors.

BACKGROUND: Undergraduate nursing students in the United States are experiencing burnout syndrome at alarming rates. There have been many attempts to improve the issue in this population, but few focus on the impact that nursing faculty have on student burnout.

METHOD: A quantitative, nonexperimental, correlational research design was used. Data were collected from Bachelor of Science in Nursing students using three valid and reliable survey tools.

RESULTS: Statistical analysis revealed the existence of a significant relationship between faculty nonverbal immediacy and all three tenets of student burnout (emotional exhaustion, cynicism, and academic efficacy). A statistically significant relationship between verbal immediacy and academic efficacy also existed.

CONCLUSION: This research demonstrates that nursing faculty who engage in immediacy behaviors may have a positive impact on the experiences of undergraduate nursing students.

PMID:42545728 | DOI:10.1097/01.NEP.0000000000001587

J Trauma Acute Care Surg. 2026 Aug 3. doi: 10.1097/TA.0000000000005148. Online ahead of print.

ABSTRACT

BACKGROUND: The risk of venous thromboembolism (VTE) in subsets of the most severely injured patients can approach 30%. Statins have anti-inflammatory properties and exert beneficial effects on the endothelium, but few previous studies have evaluated their effects on VTE in risk-stratified groups. We hypothesized that statin use was associated with lower VTE in high-risk trauma patients.

METHODS: All patients admitted to the trauma intensive care unit (ICU) from 1/2024 to 11/2024 at a single level 1 trauma center were risk-stratified using the Greenfield Risk Assessment Profile (RAP). Nontrauma patients and burn patients were excluded. Outcomes were compared between patients with and without VTE, defined by deep vein thrombosis or pulmonary embolism. Univariate analyses and multivariate logistic regression evaluated the association between statin use and VTE. Statistical significance was assessed at p≤0.05.

RESULTS: In 509 patients (age 52±22 y, 71% male, 18% penetrating injury), the average RAP score was 10±5, the overall VTE rate was 17%, and mortality was 5%. Compared with statin nonusers, statin users (n=100) were older, with more blunt injury, similar RAP scores and thromboprophylaxis use, but had a significantly lower VTE rate (8 vs. 19%, P=0.007). After RAP-based stratification, the high-risk group (RAP≥10) had a VTE rate of 28%. After controlling for confounding variables with multivariate logistic regression, statin use was independently associated with decreased VTE with an odds ratio of 0.209 (95% CI: 0.065-0.670, P=0.008).

CONCLUSIONS: Severely injured patients have high rates of VTE despite thromboprophylaxis;, however, the incidence of VTE was significantly lower among statin users. In the highest risk patients, statin use was independently associated with decreased odds of VTE. Because of their pleiotropic effects, including anti-inflammatory and endothelial protective properties, statins may be an important adjunctive therapy in VTE chemoprophylaxis. (J Trauma Acute Care Surg. 2026;00: 000-000 Copyright © 2026 Wolters Kluwer Health, LLC. All rights reserved.).

LEVEL OF EVIDENCE: Level III, therapeutic/care management.

PMID:42545722 | DOI:10.1097/TA.0000000000005148

Am J Physiol Cell Physiol. 2026 Aug 3. doi: 10.1152/ajpcell.00023.2026. Online ahead of print.

ABSTRACT

Prolonged exposure to high oxygen levels (hyperoxia) is unavoidable in managing severe Acute Respiratory Distress Syndrome (ARDS), but can itself worsen lung injury and increase mortality. Rats conditioned to be hyperoxia-tolerant (H-T) or hyperoxia-susceptible (H-S) provide a system for assessing the contribution of mitochondrial bioenergetics to the differential susceptibility to hyperoxia-induced ARDS and for identifying potential therapeutic targets. Due to the system’s complexity, interpreting lung mitochondrial bioenergetics data from these rat models requires a computational model to define which processes are altered and how changes influence overall lung tissue bioenergetics. We developed a thermodynamically constrained computational model of lung mitochondrial bioenergetics that extends prior models by incorporating regulation by ions (Ca^2⁺, H^⁺, etc.) and metabolites. The model was parameterized using experimental respirometry data from isolated lung mitochondria of conditioned (H-T, H-S) and control rats with different substrates and ADP concentrations. Model parameterization showed distinct bioenergetic changes. H-S mitochondria had reduced activity in adenine nucleotide translocase (ANT), cytochrome c oxidase (CIV), complex I (CI), and glutamate-oxaloacetate transaminase (GOT). Conversely, H-T mitochondria showed an increased activity of ANT and CIV. This supports greater metabolic flexibility in H-T mitochondria compared to H-S. Simulations of ARDS-related changes predicted divergent outcomes. H-S mitochondria underwent rapid failure, with redox collapse, loss of membrane potential, and ATP depletion. H-T mitochondria maintained bioenergetic homeostasis by enhancing electron supply via CI and complex II, with higher CIV activity. This comprehensive computational model provides a framework for identifying critical mitochondrial processes and therapeutic strategies to mitigate mitochondrial dysfunction in ARDS.

PMID:42545720 | DOI:10.1152/ajpcell.00023.2026

JAMA Pediatr. 2026 Aug 3. doi: 10.1001/jamapediatrics.2026.3239. Online ahead of print.

ABSTRACT

IMPORTANCE: Public concern and speculation have emerged around a possible link between neonatal male circumcision (NMC) and autism spectrum disorder (ASD). Evidence is limited and inconsistent.

OBJECTIVE: To examine associations between NMC and child ASD and autism-related traits and behaviors.

DESIGN, SETTING, AND PARTICIPANTS: This prospective cohort study was conducted among cohort sites participating in the Environmental Influences on Child Health Outcomes (ECHO) Cohort between February 2003 and September 2025. Statistical analyses were conducted from November 2025 to February 2026. The analysis included male, singleton children with data on NMC status and child ASD.

EXPOSURE: NMC status within 28 days of birth at a medical facility.

MAIN OUTCOMES AND MEASURES: ASD diagnosis was based on parent report of diagnosis by a medical professional or documentation of criterion standard clinical assessments. Social Responsiveness Scale (SRS-2) T-scores assessed the presence and distribution of autism traits, and Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) Autism Spectrum Problems subscale T-scores from the Child Behavior Checklist (CBCL) 1.5/5 assessed the occurrence of child autism-related behaviors.

RESULTS: The sample included 2771 male children from 14 ECHO sites, of whom 1840 (66%) were circumcised before hospital discharge, and 192 (7%) had an autism diagnosis. Among 1840 circumcised males, 108 (6%) had autism, compared with 84 of 931 uncircumcised males (9%). Mean (SD) age at autism diagnosis was 3.8 (2.2) years. Among circumcised males, 31 (4%) were administered acetaminophen during the procedure, and 128 (7%) within the 30 days after birth. After adjusting for confounders, there was no association between NMC and ASD diagnosis (odds ratio [OR], 0.83; 95% CI, 0.59-1.17). After stratification by region, preterm birth, and neonatal intensive care unit admission, an inverse or no association was observed between NMC and ASD diagnosis. Adjusted analyses showed no associations between NMC and SRS-2 continuous (β = -0.62; 95% CI, -1.46 to 0.22) or binary (OR, 0.75; 95% CI, 0.48-1.15) T-scores. Similarly, no associations were observed between NMC and CBCL 1.5/5 continuous (β = 0.01; 95% CI, -0.54 to 0.56) or binary (OR, 1.30; 95% CI, 0.75-2.26) T-scores. Overall, inverse or no associations were observed across all strata for SRS-2 and CBCL 1.5/5 outcomes.

CONCLUSIONS AND RELEVANCE: This cohort study yielded no evidence that NMC was associated with ASD risk, whether assessed by parent report of medical professional diagnosis or validated instruments measuring autism-related traits and behavior. These findings may provide reassurance for families who are considering or have elected NMC for their child.

PMID:42545713 | DOI:10.1001/jamapediatrics.2026.3239

JAMA Pediatr. 2026 Aug 3. doi: 10.1001/jamapediatrics.2026.3247. Online ahead of print.

ABSTRACT

IMPORTANCE: Current treatment for type 1 retinopathy of prematurity (ROP), including laser photocoagulation and intravitreal anti-vascular endothelial growth factor therapy, is invasive but necessary to prevent blindness. Experimental evidence and limited clinical experience suggest that topical steroids may reduce disease progression and the need for invasive treatment.

OBJECTIVE: To evaluate whether dexamethasone eye drops reduce the proportion of preterm infants with prethreshold ROP progressing to treatment-requiring type 1 ROP.

DESIGN, SETTING, AND PARTICIPANTS: The DROPROP trial was a double-masked randomized clinical trial at 6 university hospitals and 8 county hospitals in Sweden. It evaluated infants born before 30 weeks’ gestational age (GA), from 2022 to 2025, with severe ROP. Data analysis was performed from November 2025 to January 2026.

EXPOSURES: Infants were randomized to receive dexamethasone eye drops (1 mg/mL) or placebo (saline). One eye drop was administered every day or every other day for up to 12 weeks.

MAIN OUTCOMES AND MEASURES: The primary outcome was progression to type 1 ROP requiring invasive treatment. Logistic regression adjusted for GA and site was used for the primary analysis. Intention-to-treat analysis was performed. Adverse events were monitored as safety outcomes.

RESULTS: Among 100 infants, the mean (SD) GA at birth was 25.1 (1.4) weeks, 42 (42.0%) were female, and the mean (SD) birth weight was 712.9 (202.1) g. In the intention-to-treat population, type 1 ROP occurred in 10 of 50 infants (20.0%) in the dexamethasone group and 19 of 50 infants (38.0%) in the placebo group (adjusted odds ratio, 0.44; 95% CI, 0.17-1.12; P = .08), corresponding to a relative risk reduction of 47%. In the per-protocol population, type 1 ROP occurred in 9 of 48 infants (18.8%) in the dexamethasone group vs 19 of 49 infants (38.8%) in the placebo group (adjusted odds ratio, 0.40; 95% CI 0.15-1.05). No clinically significant differences in adverse events were observed between groups.

CONCLUSIONS AND RELEVANCE: Timely administration of topical dexamethasone numerically reduced the risk of prethreshold ROP progressing to treatment-requiring type 1 ROP. Although the analysis did not reach statistical significance, these findings suggest that topical dexamethasone may be a safe, noninvasive strategy to reduce the need for invasive treatment.

TRIAL REGISTRATION: euclinicaltrials.eu Identifier: 2023-505318-97-00.

PMID:42545705 | DOI:10.1001/jamapediatrics.2026.3247

JAMA Netw Open. 2026 Aug 3;9(8):e2627092. doi: 10.1001/jamanetworkopen.2026.27092.

ABSTRACT

IMPORTANCE: Medical school graduates have nonrandom geographical preferences for their location of practice, which affects patient access. The association of state policies regarding specific health care issues with medical school graduates’ preferred location of practice is not well understood.

OBJECTIVE: To characterize the association between state-level policies specific to sexual and gender minority (SGM) people and health care services (eg, gender-affirming care) and medical students’ preferred state to practice.

DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study was a secondary analysis of questionnaire responses from students graduating at Association of American Medical Colleges (AAMC) accredited US allopathic medical schools from 2020 to 2024. Eligible participants were US medical students graduating from AAMC-accredited allopathic medical schools who responded to the AAMC Matriculating Student Questionnaire in 2020 to 2024.

MAIN MEASURES AND OUTCOMES: The primary outcome was medical students’ self-reported preferred state to practice. State policy environment was categorized based on a year-by-year tally of existing laws and policies specific to SGM people and health care services. Medical students’ demographic characteristics (eg, SGM status) were self-reported. Proportional odds ordinal logistic regression estimates were performed adjusting for medical student demographic characteristics as well as additional medical student factors affecting anticipated future practice setting (ie, rurality, importance of social change in career decision-making).

RESULTS: From 2020 to 2024, there were 79 615 unique respondents (70.0% response rate), with 34 224 meeting inclusion criteria included in the analysis (18 587 aged 23 to 25 years [54.3%]; 19 549 female [57.1%]; 9755 Asian [28.5%], 2990 Black [8.7%], 4100 Hispanic [12.0%], and 19 642 White [57.4%]). A total of 4567 respondents (13.3%) reported an SGM identity. In adjusted proportional odds models, SGM status was associated with preference for higher-equality states (adjusted odds ratio [aOR], 1.56; 95% CI, 1.47-1.66; P < .001). Increasing rural practice preference was associated with lower preference for higher-equality states (aOR per category increase, 0.76 ; 95% CI, 0.75-0.77; P < .001). A greater emphasis on social change was associated with higher-equality state preference (aOR, 1.16; 95% CI, 1.13-1.19; P < .001).

CONCLUSIONS AND RELEVANCE: In this cross-sectional study, state-level policy environment was significantly associated with anticipated future practice setting preference of medical students, particularly SGM medical students; this association persisted after adjustment for demographic, professional, and temporal factors, and was resistant to extreme missing-data assumptions. Policy environment may be meaningfully associated with the anticipated distribution of the physician workforce.

PMID:42545697 | DOI:10.1001/jamanetworkopen.2026.27092

JAMA Pediatr. 2026 Aug 3. doi: 10.1001/jamapediatrics.2026.2470. Online ahead of print.

ABSTRACT

IMPORTANCE: Puberty is a critical window for bone mass acquisition, determining lifelong fracture risk. Gonadotropin-releasing hormone agonist (GnRHa)-based pubertal suppression followed by gender-affirming hormone therapy (GAHT) is increasingly used in transgender and gender-diverse (TGD) adolescents, raising concerns about peak bone mass.

OBJECTIVES: To quantify changes in bone mineral density (BMD), bone mineral apparent density (BMAD), and z scores in TGD adolescents undergoing GnRHa with or without GAHT, and to identify predictors of skeletal outcomes.

DATA SOURCES: PubMed, Scopus, Web of Science, and Cochrane Library, from inception through September 2025.

STUDY SELECTION: Longitudinal cohorts assessing BMD, BMAD, or z scores at the lumbar spine, total hip, or femoral neck in TGD adolescents treated with GnRHa with or without GAHT. Ten studies met the inclusion criteria.

DATA EXTRACTION AND SYNTHESIS: Data were extracted in duplicate; study quality was assessed using the Newcastle-Ottawa Scale. Random-effects models pooled mean changes across baseline (time 0 [T0]), after GnRHa (T1), and after GAHT (T2), stratified by skeletal site and sex assigned at birth. Metaregressions examined body mass index, age, Tanner stage, and treatment duration.

MAIN OUTCOMES AND MEASURES: Dual-energy x-ray absorptiometry-derived BMD, BMAD, and z scores.

RESULTS: Ten cohorts comprising 751 adolescents (427 assigned female at birth [AFAB]; 324 assigned male at birth [AMAB]) were included. Lumbar spine z scores declined during GnRHa (AFAB: z-score change, -0.97 [95% CI, -1.09 to -0.85]; AMAB: z-score change, -0.73 [95% CI, -0.93 to -0.53]) despite stable BMD. z Scores used sex-assigned-at-birth normative references. After GAHT, BMD increased (AFAB: BMD mean difference, 0.09 g/cm2 [95% CI, 0.07-0.10 g/cm2]; AMAB: BMD mean difference, 0.13 g/cm2 [95% CI, 0.10-0.16 g/cm2]), with partial z-score recovery; values remained below baseline at T2 (AFAB: z-score change, -0.51 [95% CI, -0.69 to -0.34]; AMAB: z-score change, -0.52 [95% CI, -0.82 to -0.21]) but were not consistently statistically different across skeletal sites. Recovery at the total hip and femoral neck was smaller and more heterogeneous. Higher body mass index, shorter GnRHa duration, and longer GAHT exposure were associated with more favorable outcomes.

CONCLUSIONS AND RELEVANCE: This systematic review and meta-analysis found that pubertal suppression followed by GAHT was associated with transient z-score reductions and subsequent BMD increases. At T2, z scores remained numerically below baseline but were not consistently statistically different, suggesting an uncertain rather than demonstrated persistent deficit. Timely GAHT initiation is recommended.

PMID:42545689 | DOI:10.1001/jamapediatrics.2026.2470

JAMA. 2026 Aug 3. doi: 10.1001/jama.2026.9350. Online ahead of print.

ABSTRACT

IMPORTANCE: In a phase 2 randomized clinical trial, high-dose vitamin D3 added to standard treatment improved progression-free survival (PFS) compared with standard-dose vitamin D3 in patients with metastatic colorectal cancer (mCRC).

OBJECTIVE: To determine if high-dose vitamin D3 added to standard chemotherapy improves outcomes in patients with previously untreated mCRC.

DESIGN, SETTING, AND PARTICIPANTS: Double-blind phase 3 randomized clinical trial enrolling 455 patients with previously untreated mCRC, conducted in the US through the National Clinical Trials Network from October 2019 to December 2022 (database freeze: July 15, 2024).

INTERVENTIONS: mFOLFOX6 (modified FOLFOX6 [5-fluorouracil, leucovorin, oxaliplatin]) or FOLFIRI (5-fluorouracil, leucovorin, irinotecan) plus bevacizumab every 2 weeks with either high-dose vitamin D3 (8000 IU daily × 14 days as loading dose followed by 4000 IU daily) or standard-dose vitamin D3 (400 IU daily) until disease progression, intolerable toxicity, or withdrawal of consent.

MAIN OUTCOMES AND MEASURES: The primary end point was PFS assessed by the unstratified log-rank test. Secondary end points included objective response rate, overall survival, and toxicity. Prespecified subgroup analyses of PFS were performed according to known prognostic factors.

RESULTS: Among 455 randomized patients (median age, 59 years; 181 [40%] female) with median follow-up 20 months, the median PFS for high-dose vitamin D3 (n = 228) was 11.8 months (95% CI, 10.3-13.3) vs 10.3 months (95% CI, 9.4-12.2) for standard-dose vitamin D3 (n = 227) (1-sided log-rank P = .25). There were no significant differences in objective response rate between high-dose and standard-dose vitamin D3 (51% [95% CI, 44%-58%] vs 44% [95% CI, 37%-50%], respectively; P = .12), or in overall survival (median, 25.6 vs 27.0 months; 1-sided log-rank P = .66). There were no clinically meaningful differences in the most common grade 3 or greater adverse events between the high- and standard-dose groups, including neutropenia (n = 67 [32%] vs n = 62 [30%]) and hypertension (n = 42 [20%] vs n = 49 [23%]) or in incidence of vitamin D-associated toxicities.

CONCLUSIONS AND RELEVANCE: Among patients with previously untreated mCRC, addition of high-dose vitamin D3, vs standard-dose vitamin D3, to standard chemotherapy plus bevacizumab did not improve PFS.

TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04094688.

PMID:42545685 | DOI:10.1001/jama.2026.9350

Int Health. 2026 Aug 3:ihag077. doi: 10.1093/inthealth/ihag077. Online ahead of print.

ABSTRACT

OBJECTIVES: Smoking is a major cause of preventable morbidity and mortality worldwide. Despite global tobacco control efforts, smoking prevalence remains high in many regions. This study aimed to determine the prevalence of smoking and its associated factors in the Kurdistan Region of Iraq.

METHODS: A community-based, cross-sectional study was conducted in 2025, consisting of 1132 individuals aged ≥18 years selected through multistage random sampling from 12 districts of Duhok City. Data were collected using a structured questionnaire and anthropometric measurements. Descriptive statistics and logistic regression analyses were performed to identify factors associated with smoking.

RESULTS: The mean age of participants was 37.5 ± 14.8 years. The overall prevalence of smoking was 33.6%, with a marked gender disparity (50.9% in men vs 5.7% in women). In univariate analysis, smoking was significantly associated with gender, education, marital status, employment status, physical activity, hypertension, waist circumference, and body mass index. Multivariate logistic regression showed that gender, education level, and employment status remained independently associated with smoking.

CONCLUSIONS: Smoking prevalence in the Kurdistan Region of Iraq is alarmingly high, particularly among men, individuals with lower education, and employed adults. These findings highlight the urgent need for strengthened tobacco control policies and targeted public health interventions in the region.

PMID:42545682 | DOI:10.1093/inthealth/ihag077

J Endocrinol Invest. 2026 Aug 3. doi: 10.1007/s40618-026-02999-w. Online ahead of print.

ABSTRACT

BACKGROUND: Pediatric obstructive sleep apnea (OSA) is an independent factor associated with cardiometabolic disease in obese youth. While chronic intermittent hypoxia alters metabolic homeostasis, evaluating this “hypoxic burden” through fasting biomarkers frequently yields inconsistent results in pediatric cohorts. We investigated whether OSA is associated with early dynamic glycemic dysfunction independent of obesity severity and evaluated the diagnostic utility of morning serum lactate.

METHODS: This retrospective cross-sectional study evaluated 53 obese adolescents (mean age 13.5 ± 1.7 years) undergoing diagnostic overnight polysomnography in a hospital setting. Participants were stratified into Mild OSA (AHI ≤ 5; n = 35) and Moderate-to-Severe OSA (AHI > 5; n = 18) cohorts. Due to the non-normal distribution of glycemic data, we performed an Analysis of Covariance (ANCOVA) using log10-transformed 2-hour OGTT glucose levels while adjusting for age. Morning serum lactate and standard metabolic indices were evaluated using non-parametric tests.

RESULTS: The Moderate-to-Severe OSA cohort demonstrated significantly elevated 2-hour OGTT glucose levels compared to the Mild OSA cohort (Median: 100 [IQR: 95-135] vs. 98 [IQR: 90-108] mg/dL; p = 0.048, Cohen’s d = 0.609). After adjusting for age as a covariate using log10-transformed data, the difference remained statistically significant (adjusted mean difference [log10]: 0.042, 95% CI [0.001 to 0.083]; p = 0.049). Morning serum lactate indicated a marginal trend toward elevation in the Moderate-to-Severe group (Median: 14.5 [IQR: 12-18] vs. 12.0 [IQR: 10-14] mg/dL; p = 0.068, Cohen’s d = 0.343). Fasting glucose and insulin levels remained comparable between groups.

CONCLUSION: Dynamic glucose dysregulation is independently associated with OSA severity in obese adolescents. The OGTT may unmask early metabolic impairment that remains hidden in fasting states.

PMID:42545670 | DOI:10.1007/s40618-026-02999-w