Nevin Manimala

J Med Internet Res. 2026 Jun 17. doi: 10.2196/92647. Online ahead of print.

ABSTRACT

BACKGROUND: Background: Depression, anxiety,, and PTSD are leading global causes of disability. Standard interventions utilize slow mechanisms of action, high attrition, and significant accessibility barriers. While intravenous (IV) and intranasal ketamine are rapid-acting alternatives, high cost and intensive logistical requirements limit adoption. Sublingual (SL) at-home ketamine addresses some gaps but is constrained by low bioavailability and variable absorption. Subcutaneous (SC) administration offers high bioavailability and precise dosing, potentially bridging the gap between in-clinic effectiveness and at-home accessibility.

OBJECTIVE: Objective: This retrospective observational study evaluated the safety, feasibility, and clinical outcomes of a telehealth, at-home SC ketamine protocol using a convenience sample of de-identified health records collected via Mindbloom’s telehealth platform across 38 states.

METHODS: Methods: A sample of N=3,870 patients with moderate-to-severe symptoms of depression (PHQ-9 ≥ 10), anxiety (GAD-7 ≥ 10), or PTSD (PCL-5 ≥ 33) participated in a structured program involving clinical assessment, mandatory peer monitoring, and remote physiological screening. Injection kits and blood pressure monitors were mailed home. Dosing followed a subanesthetic protocol starting at 0.5 mg/kg with clinician-guided titration. Primary outcomes were measured at baseline and after weeks 2, 4, and 6 using the PHQ-9, GAD-7, and PCL-5 via online survey. Linear mixed-effects models with cubic splines analyzed symptom trajectories and accounted for time-varying assessments. Statistical significance was defined as alpha = .05; effect sizes were reported. Sensitivity analyses utilized multiple imputation and LOCF.

RESULTS: Results: Patients (mean age 44.7 years; 52.4% female) demonstrated high adherence, with 0.5% switching from SC to SL administration. After 6 sessions (approximately 44 days), adjusted marginal means showed significant declines: PHQ-9 scores dropped from 14.64 (13.99-15.29) to 6.30 (5.90-6.70), GAD-7 from 13.06 (12.45-13.67) to 6.09 (5.72-6.47), and PCL-5 from 46.7 (43.30-50.10) to 27.5 (25.40-29.70) with large effect sizes ($d_z$) ranging from 1.35 to 1.58. Minimal Clinically Important Difference (MCID) was achieved by 81.8% of MDD, 80% of GAD, and 84.6% of PTSD patients ($p < .001$ for all). Adverse events were low (2.8%-3.2%), with no serious complications related to SC administration.

CONCLUSIONS: Conclusions: This study is the first large-scale evaluation of at-home SC ketamine. Results suggest at-home SC ketamine is a safe, feasible intervention associated with high rates of symptom reduction in depression, anxiety, and PTSD. It differs from existing literature by utilizing a high-bioavailability (93%) SC route in a remote setting, whereas patients typically receive infusions of this potency in-clinic. Patients achieved clinical outcomes comparable to or exceeding traditional and intranasal therapies, potentially closing the access gap for treatment-resistant populations and supporting the expansion of supervised telehealth models in mental health care.

PMID:42319752 | DOI:10.2196/92647

Indian J Pediatr. 2026 Jun 19. doi: 10.1007/s12098-026-06195-9. Online ahead of print.

ABSTRACT

OBJECTIVES: To evaluate diagnostic utility of reticulocyte hemoglobin equivalent (Ret-He) in identifying iron deficiency anemia (IDA) in acutely ill hospitalized children in comparison to serum ferritin.

METHODS: After excluding chronic inflammatory and anemic conditions unrelated to iron deficiency (ID), patients were categorized as (1) IDA: low hemoglobin+ microcytosis+ red-cell-distribution-width (RDW) index >220, (2) Non-anemia-iron-deficiency (NAID): normal haemoglobin+ microcytosis+ RDW index >220 and (3) Normal-group: normal hemoglobin+ normocytosis. Diagnostic utility indices for IDA were calculated using low hemoglobin+ microcytosis + RDW index >220 as surrogate standard. Correlation coefficients and receiver-operating-characteristic (ROC) curve cut-offs for Ret-He and ferritin were calculated.

RESULTS: Anemic (n = 180) and non-anemic (n = 66) acutely ill children, after exclusion criteria, were classified into IDA (n = 102), NAID (n = 14) and normal (n = 21). IDA group had significantly lower Ret-He levels (p <0.001). Ferritin levels showed no significant difference (p = 0.062). For IDA detection, Ret-He cut-off of 27.7 pg yielded sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of 87.2%, 80.9%, 95.7%, 56.7% and 86.2% whereas ferritin at cut-off of 147.0 ng/ml showed values of 58.8%, 66.7%, 89.5%, 25.0% and 60.2% respectively. For NAID detection, Ret-He cut-off of 29.1 pg showed sensitivity, specificity, PPV, NPV and accuracy of 71.4%, 57.1%, 52.6%, 75.0% and 62.9%, while ferritin at cut-off of 153 ng/ml showed values of 57.1%, 61.9%, 50.0%, 68.4%, and 60.0% respectively.

CONCLUSIONS: Ret-He demonstrated superior diagnostic utility compared to serum ferritin for IDA in acutely ill hospitalized children. Optimal cut-off for serum ferritin for IDA was significantly higher than WHO reference standard.

PMID:42319743 | DOI:10.1007/s12098-026-06195-9

J Robot Surg. 2026 Jun 19;20(1):613. doi: 10.1007/s11701-026-03575-3.

ABSTRACT

To compare the efficacy and safety of TiRobot-assisted versus conventional surgery for spinal deformity through meta-analysis, with age-stratified subgroup analyses in pediatric and adult patients. Comparative studies assessing TiRobot-assisted and conventional surgery for spinal deformity were systematically retrieved. Pooled analyses were conducted for operative outcomes, perioperative parameters, radiographic correction, pedicle screw accuracy, complications, and postoperative functional outcomes. Pediatric and adult subgroup analyses were subsequently performed. TiRobot-assisted surgery was associated with longer operative time overall, with statistical significance observed in pediatric patients. Screw insertion time was significantly shorter only in the pediatric subgroup. Intraoperative blood loss was significantly reduced in both pediatric and adult patients receiving TiRobot assistance. Adult patients in the TiRobot-assisted group had shorter hospital stays, whereas pediatric patients underwent fewer fluoroscopic exposures. Although overall radiographic correction was largely comparable between groups, TiRobot assistance significantly improved pedicle screw accuracy. The proportion of Gertzbein-Robbins grade A + B screws was higher, particularly in pediatric patients, while the proportion of grade 0 + 1 screws was higher in adults. In addition, TiRobot-assisted surgery significantly reduced overall and neurologic complication rates, with the reduction in neurologic complications being particularly evident in adult patients. TiRobot-assisted surgery for spinal deformity improves pedicle screw placement accuracy and perioperative safety while providing selective advantages in perioperative recovery. The pattern of benefit differs between pediatric and adult populations, but the overall balance of evidence favors TiRobot assistance over conventional techniques.

PMID:42319690 | DOI:10.1007/s11701-026-03575-3

Ir J Med Sci. 2026 Jun 19. doi: 10.1007/s11845-026-04506-9. Online ahead of print.

ABSTRACT

INTRODUCTION: Learning about conflicts of interest should be one of the core aspects aspect of clinical ethics in undergraduate and postgraduate training. However, the focus may direct more to external factors such as ties with, or inducements from, pharmaceutical interests rather than inherent fallibilities and motives of practitioners. At first sight it would appear that there is very limited concentration on the impact of income or private versus public practice on clinical practice in ethics textbooks.

METHOD: A list of clinical/medical ethics textbooks available on open shelves was established in the libraries of Trinity College Dublin, a deposit library alongside Oxford and Cambridge, each of which has rights to a copy of all publications originating in the British Isles. Two researchers independently established the presence and proportion of text relating to income or private practice in each textbook. In cases of disagreement, the senior author adjudicated. Descriptive statistics were used.

RESULTS: Of 123 ethics textbooks examined, 304 out of 38,410 pages (mean 2.5 (0.89%), standard deviation 1.73, median 0) were dedicated to the issue of income and private practice.

CONCLUSIONS: Leaders in clinical ethics should devote more emphasis to scrutiny and debate on the impact of income in addition to private and dual practice in education and research. There is significant opportunity to enhance such teaching by incorporating an informed approach to the wit and wisdom of the reflections on doctors and their income by Plautus, Molière and GB Shaw.

PMID:42319686 | DOI:10.1007/s11845-026-04506-9

Ir J Med Sci. 2026 Jun 19. doi: 10.1007/s11845-026-04485-x. Online ahead of print.

ABSTRACT

BACKGROUND: Sport-related concussion injuries are common in community Rugby Union. Despite research advancements in SRC management in recent years, little is known about the translation of research to practice within community Rugby Union cohorts.

AIMS: To develop and evaluate a novel system to track comprehensive SRC history, symptoms, and treatment data within community Rugby Union players.

METHODS: The Three-Phase Rugby Concussion System (TPRCS) collected comprehensive SRC data from players throughout the 2024-25 community Rugby Union season at baseline, 0-5 days post-SRC, and 0-5 days post-unrestricted return to play. Semi-structured interviews were conducted for stakeholders (players and club medics, n = 10) involved post-season, to evaluate participation experience, alongside perceived research facilitators, barriers, and usefulness.

RESULTS: Survey compliance ranged from 51% at baseline (n = 135), to 74% for post-SRC (n = 23), and post-clearance surveys (n = 23). The evaluation surveys received positive feedback for TPRCS’s ease of use and communication pathways, with player enthusiasm levels for study participation being the lowest-scoring survey response. The main facilitators for TPRCS included club culture, incentives, and personal contact, whilst the main barriers were absence of injury reporting and lack of prioritisation from players. Stakeholders identified education, injury treatment, and policy change as potential areas of usefulness.

CONCLUSIONS: Medics and players in community Rugby Union are enthusiastic to progress practice and behaviours in line with research. Overall, this stakeholder-evaluated comprehensive SRC data collection system can serve as a novel SRC research framework across Rugby Unions.

PMID:42319685 | DOI:10.1007/s11845-026-04485-x

Mol Biol Rep. 2026 Jun 19;53(1):958. doi: 10.1007/s11033-026-12166-2.

ABSTRACT

BACKGROUND: Breast cancer (BC) remains a leading cause of malignancy-related deaths in women. underscoring the need for low-cost, fast, sensitive and non-invasive biomarkers. MicroRNAs as a critical regulators of gene expression, with distinct expression profiles linked to tumor genesis. Particularly miR-let7a-5p and miR-34a-5p are circulating molecules with key roles in tumor suppression and proliferation, offering significant diagnostic potential.

OBJECTIVES: This exploratory study investigated the expression levels of circulating miRNAs in breast cancer patients and healthy groups and assessed their potential utility as non-invasive diagnostic biomarkers for breast cancer.

METHODS: 200 serum samples were used in this analysis, the amount of each miR expression was measured using RT-qPCR and the fold changes were determined by 2^-ΔΔCt. P-values were determined by the t-test. ROC analysis demonstrated significant diagnostic accuracy to identify BC patients.

RESULTS: Our findings indicate that circulating miR-34a-5p and miR-let-7a-5p are significant non-invasive breast cancer biomarkers, both being notably down-regulated in BC patients compared to healthy controls. With lower expression (fold change 0.503 vs. 0.810), superior diagnostic accuracy (AUC 0.8232) and higher (sensitivity 84%), miR-34a-5p outperformed let-7a-5p. No statistically significant association was identified between the studied miRNAs and age, BMI, or ER expression; however, miR-34a-5p demonstrated a weak negative correlation with PR.

CONCLUSION: Both circulating miR-34a-5p and let-7a-5p are significantly down-regulated in BC patients. MiR-34a-5p showed better accuracy on diagnostic performance, indicating its possible value as a promising non-invasive biomarker for the detection of breast cancer. This study explores the potential of these miRs in developing cost-effective strategies for breast cancer detection and risk assessment, monitoring and classification.

PMID:42319671 | DOI:10.1007/s11033-026-12166-2

J Robot Surg. 2026 Jun 19;20(1):605. doi: 10.1007/s11701-026-03532-0.

ABSTRACT

Robotic partial nephrectomy is the standard nephron-sparing approach for localised renal tumours. Whether the PADUA score continues to capture surgical complexity in the robotic era, and how patient comorbidity contributes, is uncertain. Retrospective analysis of 197 consecutive patients undergoing transperitoneal robotic partial nephrectomy by a single surgeon at two NHS sites between 2017 and 2024. The primary endpoint was trifecta achievement (warm ischaemia time ≤ 25 min, negative surgical margins, no perioperative complications). Continuous outcomes were tested with Spearman correlation and multivariable linear regression with a formal PADUA × Obesity interaction. Trifecta failure was modelled with multivariable logistic regression. Renal functional recovery was assessed with a linear mixed-effects model. Trifecta achievement was 76.1% (95% CI 69.7 to 81.6) with no significant gradient across PADUA tiers (low 80.6%, moderate 77.4%, high 71.9%; Cochran-Armitage p = 0.339). PADUA correlated with warm ischaemia time (Spearman ρ = 0.20, p = 0.007), operative duration (ρ = 0.17, p = 0.024) and length of stay (ρ = 0.19, p = 0.009). On multivariable regression PADUA independently predicted ischaemia time (β = 0.74 min per point, 95% CI 0.16 to 1.32, p = 0.013); the formal PADUA × Obesity interaction term was non-significant (β = 0.34, 95% CI – 0.88 to 1.56, p = 0.585). Mean eGFR fell at 6 months (75.4 to 71.7 mL/min/1.73 m²; paired n = 135, p < 0.001) and at 12 months (73.5 to 70.3; paired n = 60, p = 0.035), with greater decline in diabetic patients. PADUA predicts ischaemic burden, operative duration and length of stay after robotic partial nephrectomy. Obesity and diabetes contribute additively. An integrated anatomical-patient framework should accompany nephrometry in preoperative assessment, with patient-specific comorbidity profiling informing operative planning, anaesthetic risk and postoperative functional surveillance.

PMID:42319664 | DOI:10.1007/s11701-026-03532-0

Biol Trace Elem Res. 2026 Jun 19. doi: 10.1007/s12011-026-05186-3. Online ahead of print.

ABSTRACT

Bone tissue undergoes continuous remodelling throughout the life of the individual, and growth is the most impacting phase. In fact, tightly coordinated processes of resorption, synthesis, and mineralization of the bone matrix under systemic hormonal, biomechanical, and metabolic control occur for variable periods of time across species. The horse is a fast-growing animal and for this reason identified as precocial. It was hypothesized that blood serum levels of minerals in growing foals at different stages of accretion may vary over time. This investigation aimed to assess the dynamics of circulating mineral and trace element levels in serum from weaning to 24 months of age. A total of 40 serum samples (8 foals × 5 timepoints, T0-T4) were analyzed for total metals and metalloids by ICP-MS/MS (US EPA 6020B method). Each sample was measured in duplicate; the mean of the two replicate values was used in all subsequent statistical analyses. Cadmium (Cd) was the only trace element exhibiting statistically significant temporal variation throughout the growth period. A marked increase (p = 0.005) in circulating Cd was observed between T0 (6 mo.) and T1 (7 mo.), followed by a significant decline (p = 0.020) from T1 to T2 (12 mo.). Despite this population-level trend, no individual foal showed statistically significant intra-subject changes over time. All other essential trace elements remained stable, indicating preserved mineral homeostasis during growth from 6 to 24 months. These findings suggest that while essential minerals maintain a steady physiological profile during development, cadmium displays a distinct temporal pattern that may warrant further investigation. The data underscore the importance of monitoring heavy metals even in low-exposure environments during sensitive developmental windows.

PMID:42319646 | DOI:10.1007/s12011-026-05186-3

Eur J Health Econ. 2026 Jun 19. doi: 10.1007/s10198-026-01944-1. Online ahead of print.

ABSTRACT

Our study examines the relationship between business cycles and mortality rates in Italy over the period 2004-2019. Using the unemployment rate as a proxy for macroeconomic conditions, we investigate how economic fluctuations affect mortality rates across causes of death, age groups, genders, and educational levels. The analysis relies on data from the National Institute of Statistics (ISTAT) and applies panel data methods to control for province-specific heterogeneity and time effects. The findings reveal a procyclical pattern, with higher unemployment rates associated with lower mortality. Substantial heterogeneity emerges across demographic groups and causes of death. To test robustness, the analysis is extended to include the COVID-19 pandemic years (2020-2021), thereby assessing its impact on the previously identified relationships. Results suggest that the pandemic disrupted established unemployment-mortality dynamics, particularly for transport accidents and respiratory diseases. Overall, the findings highlight the importance of targeted public policies to mitigate health risks during economic expansions and provide insights into how macroeconomic conditions shape public health outcomes in Italy.

PMID:42319644 | DOI:10.1007/s10198-026-01944-1