Nevin Manimala

Cancer Epidemiol Biomarkers Prev. 2026 Jun 16. doi: 10.1158/1055-9965.EPI-25-1949. Online ahead of print.

ABSTRACT

BACKGROUND: We previously reported a significantly increased risk of thyroid cancer due to radioactive iodine-131 (131I) after the 1986 Chernobyl nuclear accident in a cohort of children and adolescents from Belarus. Radiation-related cancer risks were five times higher among those with diffuse goiter, but the relationship between radiation dose and diffuse goiter is not well understood.

METHODS: We used logistic regression to analyze data from 10,278 study participants (mean thyroid dose=0.63 gray (Gy)) who were screened 10-15 years after exposure according to a standardized protocol, which specified thyroid size assessment by both ultrasound and palpation.

RESULTS: Diffuse goiter was identified in 1,811 subjects and was significantly associated with 131I dose (P<0.001). The linear model provided the best fit to the data at doses <0.5 Gy (excess odds ratio per gray (EOR/Gy) = 1.45, 95% confidence interval (CI): 0.70, 2.41) and linear-exponential model at doses <1.5 Gy (odds ratio (OR) at 1 Gy = 1.84). Age at exposure and indicators of iodine deficiency both before the accident (place of residence) and during screening (urinary iodine levels) significantly modified the dose-response (all P-values < 0.01).

CONCLUSIONS: The first systematic evaluation of radiation risks of diffuse goiter after environmental exposure found a strong, statistically significant association with thyroid dose.

IMPACT: Our study shows that radiation exposure is associated with a significantly increased risk of developing diffuse goiter. Future epidemiological studies of iodine-deficient irradiated populations should assess thyroid size.

PMID:42301737 | DOI:10.1158/1055-9965.EPI-25-1949

JAMA Netw Open. 2026 Jun 1;9(6):e2617273. doi: 10.1001/jamanetworkopen.2026.17273.

ABSTRACT

IMPORTANCE: Differences in typical-use contraceptive failure rates between long-acting reversible contraception (LARC; such as intrauterine devices [IUDs] and implants) and shorter-acting methods (depot medroxyprogesterone acetate [DMPA], pills, rings, and male condoms) are often the focus of contraceptive counseling, but assessments of contraceptive counseling have not focused on contraceptive effectiveness over time.

OBJECTIVE: To assess 3-year continuation and typical-use contraceptive failure rates for 7 reversible contraceptive methods provided with access barriers removed.

DESIGN, SETTING, AND PARTICIPANTS: The HER Salt Lake Contraceptive Initiative was a 3-year prospective longitudinal cohort study (September 2015 to March 2017, with follow-up data collected through June 2020). Participants (new contraceptive users 18-45 years who indicated they wanted to avoid pregnancy for at least 1 year) enrolled at 4 family planning clinics in Salt Lake County, Utah, and received person-centered contraception counseling and same-day access to the reversible contraceptive method of their choice. Data were analyzed from June 2024 to February 2026.

EXPOSURE: The exposure was contraceptive method selected at baseline (copper IUD, DMPA, implant hormonal IUD, condoms, pill, or ring).

MAIN OUTCOMES AND MEASURES: The outcome was experiencing a contraceptive failure, defined as an unintended pregnancy (self-reported or identified through electronic medical record) experienced while using a contraceptive method in the previous 4 weeks. Method-specific continuation and failure rates were calculated using a life table analysis.

RESULTS: Among 4275 contraceptive users (1759 [41%] aged 20-24 years), 96 pregnancies resulting from contraceptive failures of methods initiated at baseline were identified. Of all participants, 529 (11%) selected a copper IUD, 558 (13%) selected DMPA, 823 selected an implant (19%), 1025 (24%) selected a hormonal IUD, 52 (<1%) selected condoms, 1065 (25%) selected pills, and 223 (5%) selected the ring. Cumulative continuation at 3 years included 741 hormonal IUD users (72%), 455 implant users (55%), 321 copper IUD users (61%), 186 DMPA users (33%), 75 ring users (34%), 376 pill users (35%), and 8 male condom (15%). Three-year contraceptive failure rates per 100 person-years were 0.7 (95% CI, 0.4-1.1) for hormonal IUD users, 0.8 (95% CI, 0.5-1.3) for implant users, 1.1 (95% CI, 0.6-1.8) for copper IUD users, 1.1 (95% CI, 0.6-2.1) for DMPA users, 1.4 (95% CI, 0.6-3.2) for ring users, 1.6 (95% CI, 1.1-2.3) for pill users, and 2.6 (95% CI, 0.5-10.0) for male condom users.

CONCLUSIONS AND RELEVANCE: In this cohort study of individuals initiating a contraceptive method following person-centered contraceptive counseling and removal of access barriers, low 3-year contraceptive failure rates were observed for all methods, and shorter-acting methods had lower failure rates than previously reported typical use rates. These findings suggest that removing access barriers to preferred contraceptive methods may support access to clinician-dependent LARC methods, like IUDs and implants, and improve the contraceptive effectiveness of user-controlled, shorter-acting methods.

PMID:42301715 | DOI:10.1001/jamanetworkopen.2026.17273

JAMA Netw Open. 2026 Jun 1;9(6):e2618658. doi: 10.1001/jamanetworkopen.2026.18658.

ABSTRACT

IMPORTANCE: Hip fracture is common among older adults and is associated with considerable morbidity and mortality; it is nearly twice as common in those with dementia, who may also experience worse postfracture outcomes. Time spent at home is an important quality-of-life indicator, but this outcome has not been previously examined following hip fracture in older adults with and without dementia.

OBJECTIVE: To compare days at home and survival for the year after hip fracture among older adults with and without dementia and to identify factors associated with fewer days at home among those with dementia.

DESIGN, SETTING, AND PARTICIPANTS: This longitudinal cohort study used national administrative data from 100% of Medicare beneficiaries from 2012 to 2021 to identify community-dwelling older adults (aged ≥65 years) with and without dementia hospitalized for a hip fracture. Data were analyzed from January 1, 2012, to December 31, 2021.

EXPOSURE: Hip fracture hospitalization.

MAIN OUTCOMES AND MEASURES: Days at home and survival at 30 days, 6 months, and 1 year after hip fracture.

RESULTS: Among 1 756 388 Medicare beneficiaries hospitalized for hip fracture, the mean [SD] age was 82.5 [8.1] years, 1 237 193 (70.4%) were female, 65 889 [3.8%] were Black or African American, 93 362 [5.3%] were Hispanic, 1 547 090 [88.1%] were non-Hispanic White, and 513 698 (29.2%) had dementia. In the year following hip fracture, older adults with dementia died 50.3 days earlier than those without dementia (adjusted mean [SD] days, 264.6 [143.2] vs 314.9 [107.3]). Those with dementia who survived 1 year after fracture had 53.9 fewer days at home compared with those without dementia (adjusted mean [SD] days, 263.8 [129.5] vs 317.7 [72.9]) due to more time in skilled nursing (adjusted mean [SD] days, 38.2 [55.8] vs 24.2 [37.4]) and long-term care facilities (adjusted mean [SD] days, 52.5 [111.5] vs 12.4 [53.7]). Findings were similar at 1 and 6 months. Among individuals with dementia, Medicaid eligibility, rural residence, geographic region, and being aged 85 years or older were associated with the fewest days at home at 1 year.

CONCLUSIONS AND RELEVANCE: In this cohort study, older adults with dementia had shortened survival and more time in skilled nursing or long-term care facilities after hip fracture than those without dementia. Differences in days at home were associated with structural and socioeconomic factors among those with dementia, with implications for health system policy, prognostic counseling, and discussions about long-term care needs in this population.

PMID:42301713 | DOI:10.1001/jamanetworkopen.2026.18658

JAMA Netw Open. 2026 Jun 1;9(6):e2618677. doi: 10.1001/jamanetworkopen.2026.18677.

ABSTRACT

IMPORTANCE: Beneficiaries diagnosed with cancer and enrolled in Medicare Advantage (MA) may face barriers to care due to MA plan network design. Given sizeable growth in MA enrollment, it is important to evaluate how well these plans serve patients with high health care needs.

OBJECTIVE: To examine the association between MA network breadth and changes in coverage among beneficiaries with new cancer diagnoses.

DESIGN, SETTING, AND PARTICIPANTS: This cohort used data from the 2019 to 2020 Surveillance, Epidemiology, and End Results (SEER)-Medicare and 2019 Ideon networks to examine MA plan network inclusion of American College of Surgeons Commission on Cancer-accredited facilities and National Cancer Institute-designated cancer centers. Beneficiaries enrolled in MA who were newly diagnosed with cancer in 2019 were included. Data were analyzed from October 2024 through September 2025.

EXPOSURE: The explanatory variable of interest was network breadth for these hospitals, measured as a continuous variable. Characteristics of patients in narrow networks (those with fewer than 25% of facilities in the network geographic service area that were in network) and nonnarrow networks were compared.

MAIN OUTCOMES AND MEASURES: The main outcome was any plan switch between diagnosis and January 2020, along with the kind of switch (MA to traditional Medicare or new MA plan). Multivariable logistic regression models stratified by plan type (ie, beneficiaries in employer-sponsored and retiree MA plans, plans with premiums, and plans without premiums) were used given potential differences in plan choices for these beneficiary groups. Mean marginal effects were calculated, and coefficients were scaled by 10 percentage points.

RESULTS: Among 24 444 MA beneficiaries, 13 216 individuals had plans with narrow networks (mean [SD] age, 72.2 [7.7] years; 6465 male [48.9%]; 2503 Black [18.9%], 1963 Hispanic [14.9%], and 7563 White [57.2%]) and 11 228 individuals had plans with nonnarrow networks (mean [SD] age, 73.4 [7.7] years; 5638 male [50.2%]; 1613 Black [14.4%], 1346 Hispanic [12.0%], and 7405 White [66.0%]); those in narrow networks were younger and more likely to be Black. A 10-percentage point increase in network breadth was associated with a 4.5-percentage point (95% CI, 5.5 to 3.5 percentage points; P < .001) decrease in the probability of switching to traditional Medicare or a new MA plan for beneficiaries enrolled in a nonemployer plan that charged premiums. It was not associated with enrollment changes among those in employer or retiree plans.

CONCLUSIONS AND RELEVANCE: In this study, increased network breadth was not associated with decreased Medicare plan switching for enrollees in employer plans. This finding suggests that employer subsidization of coverage may outweigh concerns about network breadth for patients newly diagnosed with cancer.

PMID:42301712 | DOI:10.1001/jamanetworkopen.2026.18677

JAMA Netw Open. 2026 Jun 1;9(6):e2618686. doi: 10.1001/jamanetworkopen.2026.18686.

ABSTRACT

IMPORTANCE: Metabolic bariatric surgery (MBS) is a highly effective but underused treatment for obesity. Greater understanding of diagnosis and referral pathways are needed to help inform appropriate treatment options for obesity.

OBJECTIVE: To examine factors associated with uptake of MBS among individuals with incident obesity diagnosis.

DESIGN, SETTING, AND PARTICIPANTS: This cohort study used insurance claims data from the Merative MarketScan Commercial Claims and Encounters Database to identify a cohort of individuals aged 18 to 64 years with an incident obesity diagnosis (index) in inpatient and outpatient settings between January 1, 2018, and December 31, 2022, as well as MBS uptake within 12 months of index to December 31, 2023.

EXPOSURES: Diagnoses classified using Agency for Healthcare Research and Quality Clinical Classifications Software Refined and therapeutic classes (Red Book) of drugs taken within the 12-month period prior to index date, as well as sociodemographic and health care factors determined at the index date.

MAIN OUTCOMES AND MEASURES: Factors associated with MBS uptake were examined using machine learning methods and multivariable logistic regression. Exclusion criteria included pregnancy-related visits; missing International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, body mass index (BMI) Z-code; or prior MBS. The top 25 factors identified by a random forest model were ranked by Shapley Additive Explanation (SHAP) values, and odds ratios (ORs) were estimated for each top factor in a multivariable logistic regression model.

RESULTS: In this study of 109 849 individuals (mean [SD] age, 41.4 [11.8] years; 63 992 women [58.3%]) with an initial obesity diagnosis, 3268 (3.0%) received MBS within 12 months of index. The area under the receiver operating characteristic curve score was 0.88 (95% CI, 0.87-0.90). The top factors identified by the random forest model included surgeon (not elsewhere classified [NEC]) as provider (which includes medical institutions and organizations as well as health care professionals) (mean SHAP value, 0.00918 [95% CI, 0.00893-0.00945]), BMI category (mean SHAP value, 0.00501 [95% CI, 0.00499-0.00503]), family practice as provider (mean SHAP value, 0.00372 [95% CI, 0.00370-0.00374]), and female sex (mean SHAP value, 0.00370 [95% CI, 0.00368-0.00371]). Surgeon (NEC) as provider had the largest OR (18.97 [95% CI, 17.11-21.02]), followed by other provider types (orthopedic surgeon: OR, 5.33 [95% CI, 4.54-6.24]; dietitian: OR, 2.51 [95% CI, 1.97-3.20]). Several medication (antidiabetic agents, miscellaneous: OR, 1.42 [95% CI, 1.25-1.62]; psychotherapeutics, antidepressants: OR, 1.13 [95% CI, 1.01-1.25]), diagnostic (depressive disorders: OR, 1.16 [95% CI, 1.02-1.33]), and sociodemographic variables (female sex: OR, 2.45 [95% CI, 2.22-2.71]) were also significantly associated with MBS. There was a significant decrease in MBS uptake for individuals with incident obesity diagnosis in more recent year-quarters from 2019 through 2022.

CONCLUSIONS AND RELEVANCE: In this cohort study of individuals with an initial obesity diagnosis, uptake of MBS was patterned by demographic, clinical, and health care factors. This finding suggests substantial opportunity to improve access to MBS through targeted policies and interventions.

PMID:42301711 | DOI:10.1001/jamanetworkopen.2026.18686

JAMA Netw Open. 2026 Jun 1;9(6):e2618698. doi: 10.1001/jamanetworkopen.2026.18698.

ABSTRACT

IMPORTANCE: Patient-directed discharge, common among hospitalized patients with opioid use disorder (OUD) experiencing opioid withdrawal, is associated with poor outcomes. Increasingly, hospital-based clinicians are using short-acting opioids alongside methadone and buprenorphine to treat opioid withdrawal. However, no published studies have examined the association between this practice and patient-directed discharge.

OBJECTIVE: To examine associations between dosing of short-acting opioids and time to first dose of short-acting opioid with early patient-directed discharge (within 72 hours).

DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study included hospitalizations involving adults with OUD who were treated with short-acting opioids between February 7 and December 31, 2024, using an opioid withdrawal order set in the electronic health record at an urban safety-net hospital. Statistical analysis was conducted between October 2024 and October 2025.

EXPOSURES: Total daily dose of short-acting opioids (oxycodone and hydromorphone) expressed in morphine milligram equivalents, and time from emergency department intake to first dose of short-acting opioid.

MAIN OUTCOMES AND MEASURES: The primary outcome was early patient-directed discharge, adjusted for age, race and ethnicity, gender, other substance use disorder, receipt of medications for OUD, and addiction care team consultation.

RESULTS: A total of 669 hospitalizations, representing 520 unique patients, were included. Patients were a mean (SD) age of 44.1 (12.2) years, with most identifying as male (531 of 669 [79.4%], with 122 of 669 female [18.2%] and 16 of 669 gender minority [2.4%]) and unhoused (555 of 669 [83.0%]). A total of 92 hospitalizations (13.8%) resulted in early patient-directed discharge. In the final adjusted model, each doubling of the patient’s daily dose of short-acting opioids was associated with an 8% reduction in the hazard of early patient-directed discharge (adjusted hazard ratio, 0.92 [95% CI, 0.86-0.99]; P = .03). There was no statistically significant association between time to first dose of short-acting opioid and patient-directed discharge within 72 hours.

CONCLUSIONS AND RELEVANCE: In this cohort study of hospitalized adults with OUD, treatment of opioid withdrawal with short-acting opioids exhibited a dose-dependent association with reduced hazard of early patient-directed discharge. These findings support the use of short-acting opioids alongside methadone and buprenorphine for inpatient treatment of opioid withdrawal.

PMID:42301710 | DOI:10.1001/jamanetworkopen.2026.18698

JAMA Netw Open. 2026 Jun 1;9(6):e2618878. doi: 10.1001/jamanetworkopen.2026.18878.

ABSTRACT

IMPORTANCE: Treatment of opioid use disorder (OUD) with buprenorphine reduces overdose and all-cause mortality, yet access and retention remain limited. Much of the literature describing barriers to buprenorphine access and retention has focused on practitioner-level or patient-level barriers, but less is known about how potential policy and payment levers may influence prescribing behaviors and treatment practices from the practitioner perspective.

OBJECTIVE: To explore perspectives among OUD treatment program clinicians and staff about how broader policy and payment structures influence adoption of buprenorphine treatment and low-barrier care practices that promote access and retention.

DESIGN, SETTING, AND PARTICIPANTS: In this qualitative study, semistructured interviews were conducted from December 2022 to July 2023. Participants included clinicians and staff from a range of outpatient treatment programs providing buprenorphine in Philadelphia, Pennsylvania.

MAIN OUTCOMES AND MEASURES: Interviews examined prescribing practices and the influence of policy, payment structures, and regulatory requirements on clinical care. Transcripts were analyzed using thematic content analysis.

RESULTS: A total of 28 practitioners and staff (13 men [46%]; 11 [39%] aged 41-50 years), including medical clinicians, therapists, and other administrative staff, were interviewed. Participants included 17 physicians (61%), 7 therapists (25%), 1 advanced practice practitioner (4%), 1 administrator (4%), and 2 other staff (8%). Twenty-four participants (86%) had at least 5 years of experience treating OUD, and all clinicians had obtained a DATA-2000 waiver, also called an X-waiver, to prescribe buprenorphine. Participants viewed the X-waiver as a symbolic barrier, but identified policy factors like insurance coverage, reimbursement rates, payer policies, and licensure requirements as key variables influencing clinical practice. Clinics relied on supplemental funding to sustain care for uninsured patients. Participants reported that payer-imposed requirements, such as prior authorizations and rigid attendance-based reimbursement, undermined timely access and individualized care and that regulatory frameworks often conflicted with harm reduction principles and created staffing and documentation burdens.

CONCLUSIONS AND RELEVANCE: This qualitative study of clinicians and staff in buprenorphine treatment programs found that broader policy and payment reforms could help support low-barrier buprenorphine treatment. Enhancing reimbursement, reducing administrative burdens, and aligning licensure and payer policies with evidence-based practices may improve access and retention. These findings offer actionable insights for policymakers, payers, and health systems seeking to address persistent gaps in OUD treatment.

PMID:42301709 | DOI:10.1001/jamanetworkopen.2026.18878

Ann Indian Acad Neurol. 2026 Jun 12. doi: 10.4103/aian.aian_1101_25. Online ahead of print.

ABSTRACT

OBJECTIVE: To evaluate the efficacy and safety of sodium phenylbutyrate-taurursodiol (PB-TURSO) and its components in slowing disease progression and improving survival in patients with amyotrophic lateral sclerosis (ALS).

METHODS: We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies comparing PB-TURSO or its components to placebo or standard of care in adults with ALS were included. The primary outcomes were functional decline (Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised [ALSFRS-R]) and survival. Two reviewers independently screened studies, extracted data, and assessed the risk of bias. A random-effects model was used for the meta-analysis, and a narrative synthesis was conducted for Tauroursodeoxycholic Acid (TUDCA) monotherapy and secondary analyses from the CENTAUR trial.

RESULTS: Two RCTs (n = 801) were included in the meta-analysis. The pooled analysis demonstrated no statistically significant difference in either ALSFRS-R decline (mean difference [MD] 1.51, 95% confidence interval [CI] -1.01 to 4.02; P = 0.24; I² =71%) or survival (hazard ratio [HR] 0.90, 95% CI 0.73-1.11; P = 0.31; I² = 61%). A separate trial of TUDCA monotherapy ( n = 34) demonstrated significant functional benefits. Post hoc analyses of the CENTAUR trial reported a survival benefit of 6.5-10.6 months and delayed progression to major disease milestones. Biomarker analyses suggested anti-inflammatory effects. The risk of bias was moderate to high, and the certainty of evidence was rated very low by GRADE.

CONCLUSIONS: Based on very low certainty evidence, the available RCT data do not support a definitive conclusion regarding the efficacy of PB-TURSO in ALS. Post hoc exploratory analyses suggest a potential survival benefit, which requires confirmation in adequately powered, prospectively designed trials; current results are hypothesis-generating rather than practice-defining.

PMID:42301697 | DOI:10.4103/aian.aian_1101_25

J Postgrad Med. 2026 Jun 16. doi: 10.4103/jpgm.jpgm_89_26. Online ahead of print.

ABSTRACT

As the WHO puts it, breastfeeding is the cornerstone of child survival, nutrition, development, and maternal health. According to NFHS data of India, only 71.2% of children under six months are exclusively breastfed in Maharashtra. The problem may be more prevalent in tribal communities due to their geographical location and strong cultural norms. This community-based cross-sectional observational study was conducted among consenting mothers of the Scheduled Tribe category with children aged six months to one year residing in the area under the Primary Health Center in a tribal village. A list of mothers fulfilling inclusion criteria was obtained from seven subcentres, and participants were selected by random sampling from each. Data was obtained by a structured interview schedule. Descriptive analysis estimated the prevalence of exclusive breastfeeding (EBF), and the association between qualitative variables was assessed by the Chi-square test. Multivariate logistic regression was applied to determine the predictors of EBF, using the software SPSS-28. A P value of ≤ 0.05 was used as the cut-off for statistical significance. Prevalence of EBF was 63.4%. Factors like age, education, occupation of mother, maternal education, place of delivery, practice of colostrum feeding, are statistically significantly associated with the practice of EBF. Multivariate logistic regression revealed that the age of the mother and the education of the father are determinants of EBF. The prevalence of EBF in the study area is lower than the state prevalence, highlighting the need for focused intervention. Furthermore, EBF practices are influenced by a mix of social, cultural, and economic factors.

PMID:42301696 | DOI:10.4103/jpgm.jpgm_89_26

Ann Indian Acad Neurol. 2026 May 1;29(3):343-352. doi: 10.4103/aian.aian_1101_25. Epub 2026 Jun 12.

ABSTRACT

OBJECTIVE: To evaluate the efficacy and safety of sodium phenylbutyrate-taurursodiol (PB-TURSO) and its components in slowing disease progression and improving survival in patients with amyotrophic lateral sclerosis (ALS).

METHODS: We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies comparing PB-TURSO or its components to placebo or standard of care in adults with ALS were included. The primary outcomes were functional decline (Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised [ALSFRS-R]) and survival. Two reviewers independently screened studies, extracted data, and assessed the risk of bias. A random-effects model was used for the meta-analysis, and a narrative synthesis was conducted for Tauroursodeoxycholic Acid (TUDCA) monotherapy and secondary analyses from the CENTAUR trial.

RESULTS: Two RCTs (n = 801) were included in the meta-analysis. The pooled analysis demonstrated no statistically significant difference in either ALSFRS-R decline (mean difference [MD] 1.51, 95% confidence interval [CI] -1.01 to 4.02; P = 0.24; I² =71%) or survival (hazard ratio [HR] 0.90, 95% CI 0.73-1.11; P = 0.31; I² = 61%). A separate trial of TUDCA monotherapy ( n = 34) demonstrated significant functional benefits. Post hoc analyses of the CENTAUR trial reported a survival benefit of 6.5-10.6 months and delayed progression to major disease milestones. Biomarker analyses suggested anti-inflammatory effects. The risk of bias was moderate to high, and the certainty of evidence was rated very low by GRADE.

CONCLUSIONS: Based on very low certainty evidence, the available RCT data do not support a definitive conclusion regarding the efficacy of PB-TURSO in ALS. Post hoc exploratory analyses suggest a potential survival benefit, which requires confirmation in adequately powered, prospectively designed trials; current results are hypothesis-generating rather than practice-defining.

PMID:42301686 | DOI:10.4103/aian.aian_1101_25