Nevin Manimala

Pain Res Manag. 2026;2026(1):e6203306. doi: 10.1155/prm/6203306.

ABSTRACT

BACKGROUND: Low back pain (LBP) is one of the most prevalent pain conditions worldwide and a major contributor to disability. Although numerous epidemiological studies have investigated LBP, heterogeneity in pain definitions and assessment indicators has limited comparability across studies. A brief and reproducible questionnaire incorporating core LBP indicators commonly used in pain epidemiology may facilitate consistent assessment of LBP occurrence and impact in population-based research.

METHODS: We proposed a brief low back pain questionnaire (B-LBPQ) designed to assess the occurrence and characteristics of LBP in epidemiological studies. The B-LBPQ consists of seven items covering current LBP, LBP during the past 12 months, lifetime experience of LBP, pain duration, and pain-related interference with daily activities. A cross-sectional validation study was conducted among 783 Japanese welfare workers aged 20-74 years (mean age: 41.9 years) undergoing routine health checkups. Construct validity was examined by comparing questionnaire-based LBP classifications with scores on the Roland-Morris Disability Questionnaire (RDQ). Internal consistency was assessed using Cronbach’s alpha. Test-retest reliability over a 2-week interval was evaluated among 595 participants using kappa statistics, prevalence-adjusted bias-adjusted kappa (PABAK), and weighted kappa coefficients.

RESULTS: Construct validity was supported by significantly higher RDQ scores among participants reporting LBP compared with those without LBP (all p < 0.001). For items with multiple response categories, significant differences and ordered trends in RDQ scores were observed across response categories (all p for trend < 0.001). Internal consistency was acceptable (Cronbach’s α = 0.87). Test-retest reliability ranged from substantial to almost perfect, with PABAK values of 0.70-0.85 for dichotomous items and weighted kappa coefficients of 0.65-0.81 for items with three or more categories.

CONCLUSIONS: The B-LBPQ demonstrated initial reliability and construct validity in Japanese welfare workers and may be useful for epidemiological assessment of LBP. However, further validation in diverse populations and settings is required.

PMID:42638610 | DOI:10.1155/prm/6203306

Anaesthesiol Intensive Ther. 2026 Aug 17;58(1):172-178. doi: 10.5114/ait/226447.

ABSTRACT

BACKGROUND: Quantitative neuromuscular monitoring is essential for the safe management of neuromuscular blockade. Although electromyography (EMG) is increasingly regarded as a reference technique, kinemyography (KMG) remains widely used in clinical practice; however, clinically relevant differences between these modalities during onset and recovery of neuromuscular blockade are not fully understood.

METHODS: In this prospective observational study, adult patients undergoing general anaesthesia with non-depolarising neuromuscular blocking agents were simultaneously monitored using EMG and KMG applied to opposite hands, and onset and recovery times of neuromuscular block were compared between modalities; additionally, a novel EMG-derived parameter (T1%) was explored as a marker of recovery.

RESULTS: In the 137 analysed patients, EMG and KMG differed during onset and recovery, with greater and only statistically significant disagreement during onset (EMG 158 ± 74 s vs. KMG 118 ± 68 s, P < 0.001; recovery: EMG 27 ± 22 min vs. KMG 24 ± 21 min, P = 0.242). T1% tended to be higher with sugammadex than with spontaneous recovery (P = 0.074).

CONCLUSIONS: KMG and EMG are not interchangeable for perioperative neuromuscular monitoring; the observed disagreement suggests that KMG may overestimate neuromuscular block, whereas EMG-based monitoring may provide a safer approach. The EMG-derived parameter T1% appears promising but requires further validation before routine clinical use.

PMID:42638596 | DOI:10.5114/ait/226447

Med Decis Making. 2026 Aug 25:272989X261472806. doi: 10.1177/0272989X261472806. Online ahead of print.

ABSTRACT

INTRODUCTION: Cost-effectiveness modelling often requires the extrapolation of survival data from clinical trials. The choice of extrapolation method is often uncertain and can have a profound effect on the results. We propose an approach that incorporates external evidence (eg, from published studies, registries, or elicited clinical opinion) into the extrapolation process to reduce uncertainty. This method can be applied to adjust previously fitted parametric curves as a secondary analysis, without access to the underlying patient-level data. Adjusted curves can be easily exported and used in spreadsheet-based models.

METHODS: Standard parametric survival curves are fitted to time-to-event data using maximum likelihood estimation (MLE). These are combined with external evidence on expected cohort-level survival at a future time point(s), formulated as a probability distribution, to generate adjusted survival curves that simultaneously incorporate both observed data and external evidence. Parameter estimation uses importance sampling and multivariate normal approximations of the likelihood. We apply our method to a case study of survival extrapolation from immuno-oncology.

RESULTS: Our method resulted in extrapolated survival predictions that were more closely aligned with the external evidence compared with the standard (MLE-based) approach. The incorporation of external evidence decreased the between-distribution variance (reduced structural uncertainty) and for most distributions also decreased within-distribution variance (reduced parametric uncertainty).

CONCLUSION: Our extrapolation method can reduce uncertainty when valid external evidence is available. Only MLE-based parameter estimates are required to implement our method; thus, secondary model users such as health technology assessment bodies can adjust survival extrapolations from existing cost-effectiveness models without access to patient-level data. Implementation is straightforward and computationally efficient, and outputs are easily incorporated into existing cost-effectiveness models.

PMID:42638584 | DOI:10.1177/0272989X261472806

Anesth Pain Med (Seoul). 2026 Aug 21. doi: 10.17085/apm.25462. Online ahead of print.

ABSTRACT

BACKGROUND: Effective postoperative analgesia is essential for optimizing recovery and patient satisfaction after inguinal hernia surgery. Therefore, we compared transdermal buprenorphine and fentanyl patches with conventional analgesia for pain control and quality of recovery-15 (QoR-15).

METHODS: In this prospective, randomized study 150 patients classified as American Society of Anesthesiologists (ASA) I-III scheduled for elective open inguinal hernia repair were randomized into three groups; (n=50 each) Group B (buprenorphine 10 µg/h patch), Group F (fentanyl 25 µg/h patch), and Group C (intravenous paracetamol and tramadol). Patches were applied 12 h preoperatively. The primary outcome was visual analog scale (VAS) pain score, assessed at 1, 6, 12, and 24 h. Secondary outcomes included QoR‑15 scores and rescue‑analgesic requirements. Statistical analysis was performed using the Kruskal-Wallis and Mann-Whitney U tests with Bonferroni correction.

RESULTS: Baseline demographic characteristics and perioperative hemodynamic parameters were comparable across groups. Median postoperative VAS scores at 6, 12, and 24 h were significantly lower in both transdermal groups than in the control group. QoR-15 scores at 24 h were 124 (122-125) (C), 127 (125-129) (F), and 133 (131-134) (B), at 48 h were 129 (128-130), 136 (134-138), and 137 (135-139) for Groups C, F, and B, respectively (P = 0.001).

CONCLUSIONS: Transdermal buprenorphine and fentanyl provided effective postoperative analgesia and were associated with improved quality of recovery compared with standard analgesia. Buprenorphine showed a significant advantage over fentanyl in QoR-15 at 24 h, however, this difference was not significant at 48 h.

PMID:42638571 | DOI:10.17085/apm.25462

J Appl Clin Med Phys. 2026 Sep;27(9):e70757. doi: 10.1002/acm2.70757.

ABSTRACT

BACKGROUND: Accurate contouring of target volumes and organs at risk is critical in radiotherapy. While deep learning (DL) models offer automated contouring, their clinical applicability to real-world cases containing anatomical variations and artifacts requires rigorous validation.

PURPOSE: To evaluate the clinical accuracy and potential vulnerabilities of RatoGuide, novel DL-based auto-segmentation software, using a dataset including atypical cases derived from routine clinical practice.

METHODS: This single-center retrospective study included 69 thoracic and male pelvic cases. The cohort was intentionally selected to encompass diverse anatomies and artifacts (e.g., pacemakers, SpaceOAR implants, artificial femoral head replacements, and unilateral atelectasis). Auto-contours generated by RatoGuide were compared with expert-approved manual contours. Performance was evaluated quantitatively using the Dice Similarity Coefficient (DSC) and 95th percentile Hausdorff Distance (HD95), and qualitatively via a 5-point visual assessment scale by four independent reviewers. Statistical comparisons between cohorts were performed using the Mann-Whitney U test. Additionally, a dosimetric evaluation was conducted for male pelvic cases to assess clinical impact.

RESULTS: In typical cases, the software maintained high segmentation accuracy (thorax: mean DSC 0.856, mean HD95 6.89 mm; male pelvis: mean DSC 0.874, mean HD95 4.11 mm). However, performance declined in atypical cohorts (thorax: mean DSC 0.808, p = 0.0457, mean HD95 12.22 mm, p = 0.0002; male pelvis: mean DSC 0.828, p = 0.1620, mean HD95 6.16 mm, p = 0.0075). Notable decreases in accuracy were observed in challenging scenarios, such as artificial femoral head replacements (DSC: 0.754) and unilateral atelectasis (DSC: 0.784). Qualitative assessment revealed that errors were primarily due to anatomical factors and artifacts. Furthermore, the dosimetric evaluation identified one critical false-negative error where a dose constraint violation was overlooked when the DL contour was used.

CONCLUSIONS: RatoGuide demonstrated favorable performance in typical cases, but accuracy declined in atypical cases with artifacts or altered anatomy. For clinical implementation, rigorous visual verification and manual review by experts are essential, particularly for atypical cases and organs in high-dose gradient regions.

PMID:42638554 | DOI:10.1002/acm2.70757

J Appl Clin Med Phys. 2026 Sep;27(9):e70765. doi: 10.1002/acm2.70765.

ABSTRACT

BACKGROUND: There is an increasing use of magnetic resonance imaging (MRI) for segmentation of target volumes and organs at risk due to superior soft tissue contrast compared to computed tomography (CT). Conventional workflows require CT-MRI registration, introducing geometric uncertainty that can propagate to dose delivery. MRI-only radiotherapy, based on AI-generated synthetic CT (sCT) and segmentations from T2-weighted images, offers a single-modality approach, potentially eliminating registration errors.

PURPOSE: Our study aims to evaluate whether an MRI-only workflow, using commercial AI models for segmentation and sCT generation (MVision), demonstrates performance comparable to expert-defined segmentations and reference CT-based calculations within the studied dataset.

METHODS: We analyzed five segmentations on 19 male pelvis patients from the Gold Atlas dataset, providing deformably co-registered CT and MRI, sCTs, with multi-observer and consensus segmentations. We investigated segmentation accuracy, image similarity, and evaluated the dosimetric impact by comparing AI- to manual segmentations and CTs to sCTs. Wilcoxon signed-rank tests were used for statistical significance and leave-one-out kappa determined segmentation outliers.

RESULTS: Results show that AI-segmentations achieved accuracy comparable to interobserver variability across all organs. Median Dice coefficients exceeded 0.9 for the prostate and bladder, and distance metrics closely matched the manual results. The leave-one-out kappa showed that AI-segmentations were indistinguishable from manual observers for all organs. sCTs showed high similarity to the reference CTs, with a median mean absolute error of 34.0 HU and median structural similarity index of 0.93. Dose recalculations showed excellent agreement; median 3D-gamma pass rate was 99.8% (2%/2 mm), and mean absolute dose difference was 0.036 Gy. All evaluated clinical dose constraints remained fulfilled after recalculation on the sCT.

CONCLUSIONS: Our results confirm that an AI-segmentation and MRI-sCT workflow provides geometric, image, and dose accuracy comparable to manual- and CT-based references, supporting their integration into clinical workflows for pelvic radiotherapy.

PMID:42638512 | DOI:10.1002/acm2.70765

J Hum Lact. 2026 Aug 25:8903344261475026. doi: 10.1177/08903344261475026. Online ahead of print.

ABSTRACT

BACKGROUND: Breastfeeding intent and practices have not been well explicated in women of color, who are likely to experience perinatal anxiety, depression, or stress.

RESEARCH AIM: The aim of this study was to examine factors influencing intent and infant feeding practices in pregnant people of color with heightened mental health conditions through 6 months postpartum.

METHOD: As part of a larger longitudinal randomized control trial, 154 Black and/or Hispanic pregnant participants reported infant feeding intent at approximately 31 weeks’ gestation, and feeding practices at 6 weeks and 6 months postpartum. Hierarchical logistic regression models examined sociodemographic characteristics, Baby-Friendly designation, and antenatal mental health symptoms as predictors of breastfeeding at 6 weeks and 6 months postpartum.

RESULTS: In this study, compared to national statistics, intent to breastfeed and initiation rates respectively, were higher in Hispanic women (96.9% and 90.6%) than in Black women (91.1% and 94.1%). In multivariable models (n = 147), maternal age was positively associated with breastfeeding at 6 weeks (aOR ≈ 1.10 per year). Delivery in a Baby-Friendly site was independently associated with higher odds of breastfeeding (aOR = 2.74-2.83 across models). Anxiety, depressive, and stress symptoms did not meaningfully attenuate this association, and none were independently associated with breastfeeding.

CONCLUSION: With supportive breastfeeding practices, women can successfully initiate breastfeeding. Mothers experiencing increased anxiety, depression, or stress, breastfed, irrespective of their mental health. Nonetheless, breastfeeding decreased over time. Further research on community resources that can continue to support vulnerable women in their breastfeeding practices is needed.

PMID:42638469 | DOI:10.1177/08903344261475026

J Appl Clin Med Phys. 2026 Sep;27(9):e70771. doi: 10.1002/acm2.70771.

ABSTRACT

BACKGROUND: Hippocampal avoidance whole-brain radiotherapy (HA-WBRT) is used to treat brain metastases while preserving cognitive function by sparing the hippocampi. Volumetric modulated arc therapy (VMAT) is commonly used due to its ability to generate conformal dose distributions. However, treatment planning remains challenging due to the need for sharp dose fall-off near centrally located hippocampi without compromising whole-brain coverage.

PURPOSE: This study evaluated the dosimetric impact of a four-arc hybrid geometry (4A-HG) and convergence mode settings for HA-WBRT using a knowledge-based planning (KBP) workflow across two linac platforms.

METHODS: Twenty HA-WBRT patients prescribed 30 Gy in 10 fractions were retrospectively studied. Plans were generated using a KBP model on two linac platforms with different collimation systems: Halcyon and Edge. Four arc configurations were evaluated, including three open-field geometries with different numbers of arcs (2A, 3A, and 4A) and 4A-HG. The 4A-HG consists of two open-field arcs and two partial-field arcs with superior-inferior field restriction near the hippocampal region, which allows improved dose modulation near the hippocampus to potentially enhance hippocampal sparing. Jaw tracking was enabled for all Edge plans. Each arc configuration was combined with three convergence modes (“Off,” “On,” and “Extended”) on both linac platforms, yielding 24 plans per patient. Plans were normalized so that 95% of the planning target volume (PTV) received 100% of prescription dose. Plan quality was evaluated using Radiation Therapy Oncology Group (RTOG) 0933 metrics, as well as by a dosimetric scorecard incorporating PTV D100% and the Paddick conformity index (PCI). Statistical comparisons were performed using Friedman tests with Holm correction. Patient-specific quality assurance (QA) was performed for the five highest-monitor-unit (MU) plans on each platform.

RESULTS: The proposed 4A-HG consistently improved target coverage and hippocampal sparing compared with conventional open-field arc configurations. Notably, PTV D100% was significantly improved with 4A-HG on the Edge with the “On” and “Extended” convergence modes (all p < 0.05 compared with other arc configurations). For example, with the “On” convergence mode, mean PTV D100% across 20 patients increased from 19.433 Gy with 2A to 20.011 Gy with 4A-HG (p = 0.009). The 4A-HG also achieved the highest mean PCI using the “Extended” mode (0.940 on Halcyon, 0.944 on Edge). Hippocampus Dmax was significantly reduced with 4A-HG on Halcyon across all modes (p < 0.01) and on Edge for “On” and “Extended” modes (p < 0.05). On Halcyon, the mean hippocampus Dmax decreased from 14.446 Gy to 13.662 Gy when changing the arc configuration from 2A to 4A-HG using the “Extended” mode, with a similar reduction observed on Edge (12.945 Gy to 12.566 Gy). More extensive convergence mode settings further improved plan quality, with the highest mean score (157/184) achieved on Edge using 4A-HG under the “Extended” mode. These improvements were associated with increased MUs; however, all QA results met institutional criteria.

CONCLUSIONS: The 4A-HG arc configuration and the more extensive convergence mode settings improved plan quality for HA-WBRT within a KBP workflow across two linac platforms. These findings support the clinical implementation of the proposed planning strategies for VMAT-based HA-WBRT.

PMID:42638463 | DOI:10.1002/acm2.70771

J Hum Lact. 2026 Aug 25:8903344261460170. doi: 10.1177/08903344261460170. Online ahead of print.

ABSTRACT

BACKGROUND: The infants of diabetic mothers are at higher risk of hypoglycemia and admittance to neonatal intensive-care units leading to failure in exclusive breastfeeding.

AIM: To determine the effects of antenatal expression of milk in late pregnancy by diabetic women on exclusive breastfeeding during the first days and 2 months after birth.

DESIGN: This was a prospective cohort study.

METHODS: A total of 106 pregnant women with diabetes who were treated at one outpatient maternity clinic and three local maternity units over a period of 2 years were recruited for the study. Patient records and structured interviews by phone were conducted to collect the data 2 months after birth. The data was analyzed statistically.

RESULTS: Most of the participants expressed breast milk during late pregnancy and did so for an average of 10 days before birth. Half of the women had challenges in breastfeeding, and only 14% exclusively breastfed their infants. The proportion of women exclusively breastfeeding was similar between those who antenatally expressed and those who did not. Women who had antenatal expressed milk were slightly more likely to use their own milk as a supplement feed. Women who found antenatal expression easy exclusively breastfed more. A higher amount of antenatal expressed milk increased exclusive breastfeeding at the hospital.

CONCLUSION: Antenatal expression of milk had no effect on exclusive breastfeeding later at home. The infants of diabetic women are at a high risk of receiving supplemental feeding after birth.

PMID:42638454 | DOI:10.1177/08903344261460170

Physiother Res Int. 2026 Oct;31(4):e70331. doi: 10.1002/pri.70331.

ABSTRACT

BACKGROUND AND PURPOSE: Although it has been assumed that higher physical activity (PA) levels will contribute to better physical fitness (PF) performance, the interplay between these two has yet to be investigated. Moreover, the majority of studies have been presented in children and adolescents, and older adults, while little is known about the correlation in the adult working population of physiotherapists. Therefore, the main purpose of the study was to examine associations between objectively measured PA and health-related PF.

METHODS: We recruited 50 physiotherapists (72.6% women) from several public and private settings in the city of Zagreb. The SenseWearArmbandPro3 (SWA), a triaxial accelerometer placed on the nondominant hand for 7 consecutive days, was used to capture total energy expenditure (TEE) and active EE (AEE). Cardiorespiratory fitness included the Harvard step test, and muscular fitness was composed of sit-ups in 60 sec and the Handgrip strength. Flexibility was evaluated using the Toe-touch test.

RESULTS: TEE and AEE were moderately and positively correlated with the Harvard step test (r = 0.65 and 0.62, p < 0.001), sit-ups (r = 0.70 and 0.59, p < 0.001), and the Handgrip strength test (r = 0.74 and 0.64, p < 0.001). No significant correlation with the Toe-touch test was observed (r = -0.25 and -0.19, p > 0.05). When models were adjusted for age, weaker, but significant positive correlations remained.

DISCUSSION: The findings suggest that both cardiorespiratory and muscular fitness are positively associated with PA, whereas no statistically significant association with flexibility was detected. Thus, it is not surprising that we obtained moderate to almost strong correlations between TEE and AEE with cardiorespiratory and muscular fitness.

CONCLUSIONS: In physiotherapists, TEE and AEE yield moderate correlations with health-related PF, especially for cardiorespiratory and muscular fitness.

PMID:42638451 | DOI:10.1002/pri.70331