Nevin Manimala

Lett Appl Microbiol. 2026 May 8:ovag046. doi: 10.1093/lambio/ovag046. Online ahead of print.

ABSTRACT

Lyme disease remains the most reported vector-borne disease in the United States, yet traditional surveillance methods rely heavily on clinical diagnosis and laboratory confirmation, both of which are subject to underreporting and diagnostic limitations. This study evaluated the feasibility of wastewater-based epidemiology (WBE) as a complementary surveillance tool for monitoring the lyme disease causing agent, Borrelia burgdorferi in a small urban community. It was conducted between 2023-2025 with 92 influent wastewater samples collected from two municipal treatment facilities in Bloomington, Indiana. Samples were concentrated using 0.45 µm pore size electronegative membrane filtration and analyzed via digital PCR for B. burgdorferi, with crAssphage quantified as a fecal normalization marker. B. burgdorferi was detected intermittently at low concentrations, with peak values reaching 3,649 gene copies/L. Detection exhibited pronounced seasonal variability, with the highest positivity occurring in fall (62.5%) and no detections observed in spring. No statistically significant differences were observed between treatment plants. Our findings indicate that B. burgdorferi can be detected in municipal wastewater and that detection patterns align with known seasonal trends in Lyme disease transmission. Despite low and intermittent detections, WBE may serve as a useful complementary population- level surveillance tool for B. burgdorferi in small urban systems.

PMID:42101881 | DOI:10.1093/lambio/ovag046

Oncologist. 2026 May 8;31(6):oyag127. doi: 10.1093/oncolo/oyag127.

ABSTRACT

BACKGROUND: Biologically based complementary and alternative medicine (BBCAM) includes special diets, dietary supplement and herbal remedies, not prescribed by a doctor or dietitian. The use of BBCAM is common among cancer survivors. BBCAM can interact with conventional treatments and unregulated products may cause harm. This study aimed to determine the prevalence, types, and motivations for BBCAM use among cancer survivors.

METHODS: A survey assessed clinical characteristics and BBCAM use in participants >18 yrs who had received cancer treatment in Ireland from 2018 to 2022.

RESULTS: Amongst 295 respondents (77% female, mean age 53 yrs), BBCAM use increased from 28% pre-diagnosis to 34% post-diagnosis (p < 0.001). For BBCAM users (n = 97, 33%), “daily-use” increased from 38% to 72% (p < 0.001) post-diagnosis. Common types included: mineral/vitamin supplements (84%), dietary supplements (e.g. turmeric, coenzyme-Q10) (78%), herbal remedies/botanicals (e.g. mistletoe, St. John’s Wort, echinacea, ginseng) (50%), cannabis (21%), and other natural products (laetrile, shark cartilage, apricot kernels) (19%). Biological medicines (GcMAF, immuno-augmentative therapy) were used by 12% of BBCAM users. Special diets including dairy free (32%), gluten-free (19%), intermittent fasting (17%), ketogenic diet (15%), juicing/detox (10%) were also common. Perceived benefits included: improved well-being (63%) and reduced psychological stress (59%).

CONCLUSION: BBCAM use increases after a cancer diagnosis. Patient perceived benefits highlight potential gaps in the current healthcare model, indicating a need for greater emphasis on safe survivorship care.

PMID:42101869 | DOI:10.1093/oncolo/oyag127

Am J Manag Care. 2026 May;32(6 Suppl):S95-S111. doi: 10.37765/ajmc.2026.89949.

ABSTRACT

BACKGROUND: Heart failure (HF) with mildly reduced ejection fraction (HFmrEF) or preserved EF (HFpEF) constitutes 74% of all HF cases in the US and is associated with significant clinical and economic burdens. Hospitalizations for HFmrEF/HFpEF are a leading contributor to the rising economic burden of HF. This literature review aims to identify key drivers of hospitalization costs for patients with HFmrEF/HFpEF in the US and to inform targeted interventions to reduce health care expenditures.

METHODS: A comprehensive search of MEDLINE and Embase was conducted to identify observational studies published between January 2022 and May 2025 that reported on hospitalization-related costs for US adults with HFmrEF/HFpEF (defined as left ventricular ejection fraction ≥ 40%). Eligible studies were those reporting direct costs of hospitalization, readmission rates, time to readmission, length of stay, and number of hospitalizations per person. Data were synthesized narratively, and costs were adjusted to 2025 US$.

RESULTS: Of 2624 records identified by the literature searches, 37 studies met inclusion criteria. Total annual costs for HFmrEF/HFpEF were $36,921 to $49,081 per person per year (PPPY), with inpatient hospitalizations accounting for nearly half ($18,844-$20,095 PPPY). Readmissions were a major cost driver, with median all-cause readmission costs ($21,371-$28,615) consistently higher than index admission costs ($13,763-$14,944). Approximately 20% of patients were readmitted within 30 days, with HF-specific readmissions accounting for one-third of 30-day readmissions. Comorbidities such as type 2 diabetes (T2D) and chronic kidney disease (CKD) significantly increased costs, with patients having multiple morbidities incurring nearly double the costs of individuals without comorbidities. Prolonged hospital stay was also linked to higher costs.

CONCLUSIONS: HFmrEF/HFpEF hospitalizations represent a significant economic burden that is driven by high inpatient costs, frequent readmissions, and coexisting conditions (eg, T2D, CKD). These findings highlight the need for improved adherence to guideline-directed medical therapy and better management of comorbidities. Policymakers and health care providers should prioritize strategies to reduce HF-related hospitalizations and readmissions to mitigate the growing economic impact of HF.

PMID:42101866 | DOI:10.37765/ajmc.2026.89949

JAMA Health Forum. 2026 May 1;7(5):e261045. doi: 10.1001/jamahealthforum.2026.1045.

ABSTRACT

IMPORTANCE: Private equity (PE) is one form of corporate investment that has rapidly expanded into primary care, with more than 2400 primary care physicians becoming PE-affiliated since 2019. There are concerns that profit incentives associated with PE investment might be detrimental to care quality and patient outcomes.

OBJECTIVE: To examine changes in patient outcomes for the traditional Medicare (TM) population after primary care practices are acquired by PE firms and to identify any changes in patient composition.

DESIGN, SETTING, AND PARTICIPANTS: This economic evaluation used a stacked difference-in-differences analysis with a 20% Medicare Part B sample from 2016 to 2022. Medicare beneficiaries with PE-acquired primary care physicians were matched to control patients based on age, risk score, sex, race and ethnicity, state of residence, and dual-eligibility status. Statistical analysis was performed from November 2024 to February 2026.

EXPOSURE: Primary care practice acquisition by a PE firm, identified using PitchBook data.

MAIN OUTCOMES AND MEASURES: Primary outcomes at the patient-quarter level include number of all-cause hospitalizations, number of potentially avoidable hospitalizations for ambulatory-sensitive conditions, and number of emergency department (ED) visits. Secondary outcomes include measures of patient composition, including patient age, sex, race and ethnicity, and hierarchical condition category score.

RESULTS: The analysis included 24 397 beneficiaries with PE-acquired primary care physicians, matched to 121 939 control patients. The mean (SD) age was 74 (10) years, and 56% of patients were female. After PE acquisition, the number of all-cause ED visits decreased by 1.36% (95% CI, -2.72% to -0.14%) per patient-quarter relative to baseline. Considering various sensitivity tests, there were no significant changes to the probability of or number of potentially preventable hospitalizations or all-cause hospitalizations. Patient composition remained unchanged.

CONCLUSIONS AND RELEVANCE: In this national study of traditional Medicare beneficiaries, PE acquisitions of primary care practices were not associated with meaningful short-term changes in acute care outcomes. Overall, findings contribute to policy discourse on understanding the role of PE investments in shaping care quality, suggesting heterogeneity in outcomes across health care settings.

PMID:42101854 | DOI:10.1001/jamahealthforum.2026.1045

JAMA Netw Open. 2026 May 1;9(5):e2616556. doi: 10.1001/jamanetworkopen.2026.16556.

ABSTRACT

IMPORTANCE: High-quality discharge summaries are essential for safe care transitions but contribute substantially to clinician documentation burden and burnout. While retrospective studies suggest that large language models (LLMs) can generate clinical summaries of comparable quality to those by physicians, prospective data on their safety, utility, and association with clinician well-being in clinical environments are lacking.

OBJECTIVE: To evaluate the safety, use, and association with clinician burden of MedAgentBrief, an LLM-based agentic workflow for generating hospital course summaries, during prospective clinical deployment.

DESIGN, SETTING, AND PARTICIPANTS: This single-arm prospective pilot quality improvement study encompassed hospital discharges at 1 academic inpatient medicine unit from August 1 to October 11, 2025, with baseline comparisons drawn from April 9 to July 31, 2025.

INTERVENTION: A custom agentic LLM workflow using Gemini 2.5 Pro generated draft hospital course summaries nightly using patient history and physical and daily progress notes. Drafts were securely emailed to physicians daily for review and optional use.

MAIN OUTCOMES AND MEASURES: The primary outcome was physician-reported potential for and severity of harm from unedited summaries (Agency for Healthcare Research and Quality Common Format Harm Scale). Secondary outcomes included use rate, error types (omissions, inaccuracies, and hallucinations), time spent in discharge summaries (electronic health record logs), and changes in cognitive burden (NASA Task Load Index; score range, 0-100, with higher scores indicating greater cognitive burden) and burnout (Stanford Professional Fulfillment Index Work Exhaustion Scale; score range, 0-4, with higher scores indicating greater burnout).

RESULTS: Among 384 hospital discharges, the system generated 1274 summaries. Physicians used artificial intelligence (AI) content in 219 cases (57.0%). Feedback on 100 summaries (88 of 219 used summaries [40.2%] and 12 of 165 unused summaries [7.3%]) noted omissions (25 summaries [25.0%]) and inaccuracies (20 summaries [20.0%]) but rare hallucinations (2 summaries [2.0%]). Physicians rated 88 unedited summaries (88.0%) as having no harm potential and 1 (1.0%) as likely to cause moderate harm; no severe harm was reported. Mean physician burnout scores decreased significantly from before to after the intervention (1.75; 95% CI, 1.16-2.34 vs 1.20; 95% CI, 0.71-1.69; P = .03). Time savings were heterogeneous, with 5 of 7 physicians with matched baseline data (71.4%) seeing reductions in median documentation time; changes from baseline to pilot were up to 2.9 minutes, which was a nonsignificant difference (10.7 minutes; 95% CI, 7.4-13.3 minutes vs 7.8 minutes; 95% CI, 5.1-11.7 minutes; P = .13).

CONCLUSIONS AND RELEVANCE: In this study, an LLM-based agentic workflow produced hospital course summaries that were frequently used with minimal risk of harm identified. The intervention was associated with a reduction in physician burnout, supporting the viability of AI summarization to mitigate documentation burden.

PMID:42101844 | DOI:10.1001/jamanetworkopen.2026.16556

JAMA Netw Open. 2026 May 1;9(5):e266147. doi: 10.1001/jamanetworkopen.2026.6147.

ABSTRACT

IMPORTANCE: The US has higher mortality rates than other high-income countries (HICs). However, a comprehensive analysis of excess US deaths encompassing all leading causes of death over the past 2 decades is currently lacking.

OBJECTIVE: To investigate causes of death responsible for excess US mortality compared with other HICs and how the causes of death involved in this US mortality disadvantage have changed over time.

DESIGN, SETTING, AND PARTICIPANTS: This repeated cross-sectional study included mortality data from the World Health Organization Mortality Database spanning 1999 to 2022 for the US and 17 other HICs. Data were analyzed from September 2023 to December 2025.

EXPOSURES: Residing in the US vs another of the included HICs.

MAIN OUTCOME AND MEASURES: The main outcome was excess US mortality in each year due to specific causes of death. Differences between the US and other HICs were quantified for each cause of death as (1) excess US deaths (ie, absolute difference between observed deaths and deaths expected if US death rates equaled the rates of other HICs); (2) years of life lost (YLL) resulting from excess US deaths; and (3) mortality rate ratios (ie, ratios of observed to expected age-standardized death rates).

RESULTS: A total of 63 547 318 deaths occurred in the US from 1999 to 2022 (50.4% among males; mean [SD] age at death, 73.2 [18.5] years). In this period, 12 675 646 excess US deaths occurred, increasing from 346 166 in 1999 to 905 159 in 2022. Circulatory diseases were the leading cause of excess US deaths every year except 2010, increasing after 2001 for ages 45 to 64 years and after 2009 for ages 65 years or older. Together, circulatory and metabolic diseases accounted for 52% of excess US deaths in 2022. Excess US deaths due to drug poisonings, alcohol, and suicide increased from -5762 in 1999 to 131 151 in 2022; together, these 3 causes accounted for 24% of the increase in excess US deaths overall and most of the increase in excess US deaths for individuals aged 0 to 44 years. In 2022, deaths from drug poisonings were 7.48 times higher in the US than in other HICs. In 2020 and 2021, 19% and 23% of excess US deaths, respectively, were attributed to COVID-19, but excess US deaths from other causes also increased.

CONCLUSIONS AND RELEVANCE: In this repeated cross-sectional study of cross-national mortality, the US had substantially higher death rates than other HICs between 1999 and 2022, despite having similar access to advanced medical technology. Many of these excess US deaths could likely be avoided by adopting health and social policies that have benefited other HICs. These descriptive findings should be interpreted in light of uncertainty arising from differences in death coding, data completeness, and other aspects of data comparability across countries.

PMID:42101842 | DOI:10.1001/jamanetworkopen.2026.6147

JAMA Netw Open. 2026 May 1;9(5):e2611418. doi: 10.1001/jamanetworkopen.2026.11418.

ABSTRACT

IMPORTANCE: Smoking cessation interventions could ultimately offer greater impact to the extent that they are brief, concrete, and face valid (to the individuals presenting and receiving the intervention), which would then make these interventions scalable across a broad spectrum of adults who smoke (AWS). Medication sampling is one potential strategy to meet that need.

OBJECTIVE: To determine outcomes of varenicline sampling in a fully powered randomized clinical trial (RCT), conducted from February 2021 to April 2025.

DESIGN, SETTING, AND PARTICIPANTS: This decentralized RCT included non-treatment seeking AWS with varying levels of motivation to quit who were recruited throughout South Carolina.

INTERVENTION: Participants were randomized to receive a 4-week sample of varenicline, nicotine replacement therapy (NRT; active control), or quitline referral (inactive control) in a 2:1:1 ratio. Accompanying 4-week medication supply, intervention messaging in both sampling groups emphasized naturalistic use, ie, a participant-driven experience with self-determined uptake, use, and goals for use.

MAIN OUTCOMES AND MEASURES: The primary outcome was self-reported 7-day point prevalence abstinence (PPA) at 6-month follow-up. Secondary outcomes included carbon monoxide (CO)-verified abstinence, floating abstinence (any 7-day period of not smoking throughout follow-up), quit attempts, and smoking reduction.

RESULTS: The study sample included 651 AWS (mean [SD] age, 52 [11] years; 431 (66%) female), with 161 randomized to the no-sampling control, 172 randomized to NRT, and 318 randomized to varenicline. Compared with the no-sampling control, AWS receiving varenicline samples had higher rates of self-reported PPA at month 6 (16 of 161 [10%] vs 53 of 318 [17%]; P = .048), floating abstinence throughout follow-up (33 [20%] vs 108 [34%]; P = .003); and greater incidence of 50% or greater reduction in cigarettes per day (CPD) by 6 months (31 [19%] vs 106 [33%]; P = .002); however, rates of CO-verified abstinence at 6 months were not significantly different. Varenicline sampling was superior to NRT sampling for 6-month self-reported abstinence (53 [17%] vs 14 of 172 [8%]; P = .01); floating abstinence through 6 months (108 [34%] vs 43 [25%]; P = .04); and incidence of 50% or greater reduction in CPD at week 8 (111 [35%] vs 38 [22%]; P = .005) but not at 6 months.

CONCLUSIONS AND RELEVANCE: In this RCT of 651 AWS, varenicline sampling was efficacious, with potentially superior outcomes compared with NRT. Results provide additional evidence in support of medication sampling as a pragmatic option to engage AWS in cessation, worth further evaluation within an applied settings.

TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04525755.

PMID:42101840 | DOI:10.1001/jamanetworkopen.2026.11418

JAMA Netw Open. 2026 May 1;9(5):e2611700. doi: 10.1001/jamanetworkopen.2026.11700.

ABSTRACT

IMPORTANCE: The ultimate goal of residency education is to train physicians to deliver high-quality patient care. However, residents rarely receive data-driven feedback because resident-level quality measures are lacking.

OBJECTIVE: To develop and evaluate resident-sensitive quality measures (RSQMs) using electronic health record data to inform graduate medical education.

DESIGN, SETTING, AND PARTICIPANTS: This cohort study used call schedules linking senior internal medicine residents to patient admissions during overnight internal medicine call shifts at 5 teaching hospitals in Canada from July 1, 2010, through December 31, 2019. Using clinical practice guidelines, 7 RSQMs related to pneumonia or general care for all internal medicine admissions were developed. To support interpretation, a care variation framework was applied that categorized measures as low value (not recommended), discretionary (context dependent), or evidence based (recommended) to enable comparisons between observed and expected variation. The data were analyzed between March 1, 2024, and February 23, 2026.

MAIN OUTCOMES AND MEASURES: The low-value care RSQM measured potentially inappropriate red cell transfusions (all admissions). Discretionary RSQMs measured use of antibiotics, imaging, or blood work for either pneumonia or all admissions. The evidence-based care RSQM measured ordering of first-line antibiotics for pneumonia. Resident-level variation was assessed using descriptive statistics, including the median proportion of eligible admissions with each RSQM performed and interquartile range.

RESULTS: The cohort included 132 291 patient admissions (median [IQR] age, 70 [55-83] years; 50.6% male) linked to 793 residents. Residents had a median (IQR) of 187 (89-228) admissions, including a median (IQR) of 18 (10-24) admissions for pneumonia. Potentially inappropriate red cell transfusions occurred in a low proportion of encounters, with little variation (median, 0%; IQR, 0%-0%). Discretionary measures, including use of second-line antibiotics, advanced imaging, chest computed tomography, and serum protein electrophoresis, varied across residents. For pneumonia admissions (n = 13 470), the RSQM for first-line antibiotic use in pneumonia was sensitive to the time windows for included orders, ranging from 22% (3027 admissions) to 76% (10 205 admissions), depending on the cutoffs applied.

CONCLUSIONS AND RELEVANCE: This cohort study outlined an approach to developing and evaluating RSQMs using readily available electronic health record data to evaluate internal medicine residents’ quality of care. Although the RSQMs showed potential, their use for inpatient internal medicine may be more appropriate at the program level due to unresolved concerns regarding attribution and statistical reliability.

PMID:42101838 | DOI:10.1001/jamanetworkopen.2026.11700

JAMA Netw Open. 2026 May 1;9(5):e2611711. doi: 10.1001/jamanetworkopen.2026.11711.

ABSTRACT

IMPORTANCE: Urine drug testing (UDT) is commonly used in substance use disorder (SUD) treatment. However, there is little evidence to guide optimal use of UDT and growing concern that some UDT may represent low-value care.

OBJECTIVE: To determine whether a statewide policy limiting Medicaid reimbursement for UDT is associated with testing frequency, expenditures, and clinical outcomes.

DESIGN, SETTING, AND PARTICIPANTS: This serial cross-sectional study was performed among Louisiana Medicaid beneficiaries between July 1, 2017, and February 29, 2020. Data were analyzed from November 1, 2024, to November 30, 2025. For each outcome, best-fit lines for pre-enactment trends were constructed and used to estimate postenactment trends, which were then compared with observed trends. The 3-way interaction of time by intervention period by outcome was analyzed to assess changes for each UDT utilization outcome compared with a matched control procedure (colonoscopy). Concomitant trends in overdose encounters and prescription of medications for opioid use disorder (MOUD) were also assessed.

EXPOSURE: Statewide policy limiting Medicaid reimbursement for UDT enacted in July 2019. Colonoscopy rates were used as a temporal comparison procedure.

MAIN OUTCOMES AND MEASURES: Outcomes included rates of monthly UDT (total, presumptive, and definitive) and expenditures per 1000 beneficiaries for 24 months before and 7 months after policy enactment.

RESULTS: The sample included a total of 900 678 unique Medicaid-eligible beneficiaries, 536 841 (59.6%) of whom were female and 606 012 (67.3%) were younger than 40 years. Following policy enactment, the monthly rate of change for total UDT utilization decreased from 0.67 (95% CI, 0.48- 0.85) to -1.03 (95% CI, -1.65 to -0.40) tests per month per 1000 beneficiaries (difference, -1.70 [95% CI, -2.34 to -1.06] tests per month per 1000 beneficiaries); presumptive UDT decreased from 0.42 (95% CI, 0.30-0.53) to -0.63 (95% CI, -0.92 to -0.35) tests per month per 1000 beneficiaries (difference, -1.05 [95% CI, -1.36 to -0.74] tests per month per 1000 beneficiaries); and definitive UDT decreased from 0.25 (95% CI, 0.17-0.34) to -0.39 (95% CI, -0.97 to 0.18) tests per month per 1000 beneficiaries (difference, -0.65 [95% CI, -1.23 to -0.07] tests per month per 1000 beneficiaries). These decreases were all statistically significant compared with colonoscopy (all P < .05). UDT expenditures also significantly decreased, totaling an estimated $14.8 million in savings during the 7-month postenactment period. The policy change was not associated with reduced MOUD receipt or increased overdose encounters.

CONCLUSION AND RELEVANCE: In this cross-sectional study, a state policy limiting reimbursement for UDT was associated with significant reductions in UDT utilization and expenditures. Future research and policymaking should investigate ways to optimize UDT for patient health while reducing low-value care.

PMID:42101837 | DOI:10.1001/jamanetworkopen.2026.11711

Rev Sci Instrum. 2026 May 1;97(5):055208. doi: 10.1063/5.0314932.

ABSTRACT

Soft x-ray angle-resolved photoemission spectroscopy (SX-ARPES) is one of the most powerful spectroscopic techniques to visualize the three-dimensional bulk electronic structure in reciprocal lattice space. Compared with ARPES employing low-energy photon sources, the time burden imposed by a lower photoelectron yield, stemming from the photoionization cross-section, has been a persistent technical challenge. To address this challenge, we have developed a noise-reduction system by using the deep prior-based approach and integrated it into the micro-focused SX-ARPES (μSX-ARPES) system at BL25SU in SPring-8. The implemented system effectively eliminates instrumental artifacts, such as grid and spike structures typical of ARPES data acquired using the voltage Fixed mode, within ∼30 s. We demonstrate, through the μSX-ARPES measurements on a single crystal of CeRu2Si2, that data with sufficient statistical accuracy can be obtained in ∼40 s. In addition, we present the potential of high signal-to-noise ratio ARPES measurement, achieving an energy resolution of 51.6 meV at an excitation energy of 708 eV in μSX-ARPES measurements on polycrystalline gold. Our developed system successfully reduces the time burden in SX-ARPES and paves the way for advancements in lower photoelectron yield measurements, such as those requiring higher energy resolution and three-dimensional nonequilibrium measurements.

PMID:42101827 | DOI:10.1063/5.0314932