Nevin Manimala

J Med Internet Res. 2026 Mar 24;28:e72083. doi: 10.2196/72083.

ABSTRACT

BACKGROUND: The prediction of the onset of sepsis, a life-threatening condition resulting from a dysregulated response to an infection, is one of the most common prediction tasks in intensive care-related machine learning research. To assess the performance of such models, different evaluation strategies, including fixed horizon (a single prediction at a set time before onset), peak score (a single prediction using the maximum predicted risk across time), and continuous evaluation (multiple predictions assessed continuously across time), are commonly implemented, but there is no clear consensus on which approach should be used in order to provide clinically meaningful performance evaluation.

OBJECTIVE: This study aimed to assess different evaluation approaches of sepsis prediction models trained on a public intensive care dataset applied to German intensive care data.

METHODS: In this retrospective, observational cohort study, we assessed the efficacy of machine learning models, pretrained on the Medical Information Mart for Intensive Care IV dataset, when applied to BerlinICU, a multisite German intensive care dataset. To understand the real-world impact of implementing these models, we examined the performance variability across various evaluation strategies.

RESULTS: The BerlinICU dataset includes 40,132 intensive care admissions spanning 10 years (2012-2021). Using the latest Sepsis-3 definition, we identified 4134 septic admissions (10.3% prevalence). Application of a temporal convolutional network model to BerlinICU yielded an area under the receiver operating characteristic curve (AUROC) of 0.67 (95% CI 0.66-0.68) for continuous evaluation with a 6-hour prediction horizon, compared with 0.84 (95% CI 0.83-0.85) on the test set of Medical Information Mart for Intensive Care IV. On BerlinICU, peak score evaluation showed a similar AUROC compared with continuous evaluation, while fixed horizon evaluation showed a reduced AUROC of 0.61 (95% CI 0.60-0.62). Onset matching had minimal impact on performance estimates using continuous evaluation or fixed horizon evaluation, but increased estimates for peak score evaluation. Performance metrics improved with shorter prediction horizons across all strategies.

CONCLUSIONS: Our results demonstrate that the choice of evaluation strategy has a significant impact on the performance metrics of intensive care prediction models. The same model applied to the same dataset yields markedly different performance metrics depending on the evaluation approach. Therefore, careful selection of the evaluation approach is essential to ensure that the interpretation of performance metrics aligns with clinical intentions and enables meaningful comparisons between studies. In our view, the continuous evaluation approach best reflects the continual monitoring of patients that is performed in real-world clinical practice. In contrast, fixed-horizon and peak score evaluation approaches may produce skewed results when not properly matching the length of stay distributions between sepsis cases and control cases. Especially for peak score evaluation, longer visits tend to produce higher maximum scores because sampling from more values increases the likelihood of capturing higher values purely by chance.

PMID:41874553 | DOI:10.2196/72083

J Acoust Soc Am. 2026 Mar 1;159(3):2754-2778. doi: 10.1121/10.0043155.

ABSTRACT

Road traffic noise represents a major source of environmental pollution, and its prediction remains a critical task. This challenge particularly emerges when traffic data are not available, such as during the design phases of new infrastructures, where it becomes necessary to predict the noise exposure affecting nearby residents, even in the absence of measurement data. To address this issue, this work augments a previously developed microscopic and stochastic-core traffic noise model, integrating it with forecasting time series models for traffic flows and average vehicle speeds. This integration produces a hybrid model that enables the estimation of hourly traffic noise levels based solely on historical traffic patterns, even in the absence of direct traffic observations for the period under investigation. The methodology has been evaluated through a statistical analysis of simulated noise levels, with a focus on error distribution and conventional error metrics. The mean error of 0.43 dBA and the mean absolute error of 1.30 dBA confirm the accuracy of the proposed approach for estimating road traffic noise in data-scarce scenarios. A comparison with the CNOSSOS-EU model’s performance highlights the possibility of using such methodology in early-stage infrastructure design and planning.

PMID:41874545 | DOI:10.1121/10.0043155

J Med Internet Res. 2026 Mar 24;28:e89102. doi: 10.2196/89102.

ABSTRACT

BACKGROUND: With expansion of technology-enabled care, digital health literacy (DHL) has become integral to effective cardiovascular disease (CVD) management. However, quantitative evidence regarding determinants and health outcomes of DHL in CVD remains limited and heterogeneous, necessitating comprehensive evidence synthesis.

OBJECTIVE: This study aimed to (1) estimate DHL levels, (2) synthesize DHL-associated factors, and (3) examine DHL-related health outcomes in CVD.

METHODS: A systematic review and meta-analysis of DHL in adults with CVD was conducted per PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 guidelines. PubMed, Embase, Cochrane CENTRAL, CINAHL, Scopus, Web of Science, and Google Scholar were searched for peer-reviewed studies published between 2006 and January 31, 2026. Quantitative studies enrolling adults with CVD, which reported a measure of DHL were included. Studies focusing exclusively on primary cerebrovascular disease and non-peer-reviewed articles were excluded. Risk of bias (ROB) was assessed using the Appraisal Tool for Cross-Sectional Studies tool, the Newcastle-Ottawa Scale, the Revised Cochrane Risk-of-Bias Tool for Randomized Trials, and the Risk of Bias in Nonrandomized Studies of Interventions. Certainty of evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation approach. Pooled mean eHealth Literacy Scale (eHEALS) scores were synthesized using a random-effects meta-analysis. Heterogeneity was quantified using the I² statistic and 95% prediction intervals.

RESULTS: Twenty studies involving 8581 adults with CVD were included. The overall pooled mean eHEALS score was 24.26 (95% CI 21.19-27.32), with substantial heterogeneity (I²=98.4%; τ²=15.55; τ=3.94) and a wide 95% prediction interval (14.66-33.85). Lower DHL was consistently associated with older age, lower educational attainment, female sex, limited social support, and less experience with digital technologies. Higher DHL was associated with more favorable health-related outcomes, including health behaviors, better quality of life, and greater use and acceptance of digital health technologies. Subgroup analyses showed no statistically significant differences in DHL by region, disease type, or age group. The certainty of evidence was rated as low to very low, and substantial heterogeneity persisted across analyses.

CONCLUSIONS: Our findings underscore DHL as a foundational capability for digitally supported self-management in CVD care and reveal disparities associated with age and socioeconomic factors. By integrating evidence on DHL levels, associated factors, and DHL-related health outcomes in CVD populations, this review provides a more comprehensive, clinically relevant understanding of DHL beyond studies relying on a single instrument (eg, eHEALS) or examining isolated domains. DHL appears to be a context-dependent competency shaped by broader structural and social determinants. From a clinical and health system perspective, digital health interventions should be accompanied by structured digital inclusion strategies, including routine assessment of DHL and care delivery to patients’ digital capacities. Further longitudinal and interventional studies are warranted to clarify the causal pathways linking DHL to health outcomes in adults with CVD and to incorporate provider- and system-level perspectives beyond individual-level assessments.

TRIAL REGISTRATION: PROSPERO International Prospective Register of Systematic Reviews CRD420251068000; https://www.crd.york.ac.uk/PROSPERO/view/CRD420251068000.

PMID:41874540 | DOI:10.2196/89102

Elife. 2026 Mar 24;13:RP97848. doi: 10.7554/eLife.97848.

ABSTRACT

Among brain areas, axonal projections carry channels of information that can be mixed to varying degrees. Here, we assess the rules for the network consisting of the primary visual cortex and higher visual areas (V1-HVA) in mice. We use large field-of-view two-photon calcium imaging to measure correlated variability (i.e. noise correlations, NCs) among thousands of neurons, forming over a million unique pairs, distributed across multiple cortical areas simultaneously. The amplitude of NCs is proportional to functional connectivity in the network, and we find that they are robust, reproducible statistical measures and are remarkably similar across stimuli, thus providing effective constraints to network models. We used these NCs to measure the statistics of functional connectivity among tuning classes of neurons in V1 and HVAs. Using a data-driven clustering approach, we identify approximately 60 distinct tuning classes found in V1 and HVAs. We find that NCs are higher between neurons from the same tuning class, both within and across cortical areas. Thus, in the V1-HVA network, mixing of channels is avoided. Instead, distinct channels of visual information are broadcast within and across cortical areas, at both the micron and millimeter length scales. This principle for the functional organization and correlation structure at the individual neuron level across multiple cortical areas can inform and constrain computational theories of neocortical networks.

PMID:41874539 | DOI:10.7554/eLife.97848

J Strength Cond Res. 2026 Apr 1;40(4):439-450. doi: 10.1519/JSC.0000000000005333.

ABSTRACT

Nakamura, H, Yamashita, D, Nishiumi, D, Nakaichi, N, and Hirose, N. The determinants of deceleration and reacceleration abilities in pro-agility test in adolescent soccer players. J Strength Cond Res 40(4): 439-450, 2026-This study investigated how deceleration and reacceleration abilities in a Pro-Agility test are influenced by kinematic, physical, and maturation factors in male adolescent soccer players. Seventy-one soccer players performed jump tests (standing long jump, countermovement jump, squat jump) and a Pro-Agility test. Kinetic variables during countermovement and squat jumps were obtained using dual force plates, and 3-dimensional kinematic data from the Pro-Agility test were obtained using a markerless motion capture system. In the Pro-Agility test, the deceleration and acceleration phases were determined from the center-of-mass (COM) velocity and subdivided into early and late halves. The mean COM deceleration (Dec) and acceleration (Acc) were calculated in each phase and event. A linear mixed model was used to identify the variables predicting Dec and Acc. Statistical significance was set at p < 0.05. Both first late Dec and second late Dec were associated with Dec during penultimate foot contact (β = 0.231 and β = 0.197, respectively) and COM height at the final foot contact (β = 5.431 and β = 2.910, respectively). Both second early Acc and third early Acc were associated with peak propulsive force in squat jump (β = 0.050 and β = 0.086, respectively). Second early Acc was associated with body height (β = 0.086), and third early Acc was associated with chronological age (β = 0.086), but not with deceleration abilities. These findings highlight the importance of tailoring training strategies to enhance overall change-of-direction performance.

PMID:41874530 | DOI:10.1519/JSC.0000000000005333

JAMA Netw Open. 2026 Mar 2;9(3):e260755. doi: 10.1001/jamanetworkopen.2026.0755.

ABSTRACT

IMPORTANCE: Hospice is central to end-of-life (EOL) care for patients with advanced cancers and is an excluded benefit under Medicare Advantage (MA), with coverage instead provided by traditional Medicare (TM). With growing MA penetration, more beneficiaries also switch between MA and TM for financial protection and physician access considerations, although less is known about how different Medicare programs and plan switching behaviors affect EOL care for patients with advanced cancers.

OBJECTIVE: To evaluate hospice utilization and places of hospice care by Medicare plan switching patterns.

DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study used Surveillance, Epidemiology, and End Results (SEER) Medicare data to identify beneficiaries aged ≥66 years diagnosed with distant-stage female breast, colorectal, lung, pancreatic, or prostate cancers from 2010 to 2019 who died by 2020. Beneficiaries were followed for up to 1 year before death. Data were analyzed from August 1, 2024, to December 14, 2025.

EXPOSURE: Plan switching patterns classified as continuous MA, continuous TM, MA to TM, TM to MA, and other (ie, multiple switches).

MAIN OUTCOMES AND MEASURES: Main outcomes were hospice enrollment in the last year of life and within 3 days of death, total hospice length of stay, and place of last hospice stay (home, nursing home, hospice facility, inpatient facility, or other) using multivariable regressions.

RESULTS: The sample included 196 536 decedents (46.5% female, 49.2% aged 66-74 years). Plan switching was infrequent (1.5% TM to MA; 1.8% MA to TM). Those who switched plans were more likely to be members of racial and ethnic minority groups and dual Medicare-Medicaid enrollees. Hospice enrollment was highest for those with continuous MA (74.8%), followed by those who switched from TM to MA (69.0%), those with continuous TM (68.5%), and those who switched from MA to TM (66.4%). Continuous MA beneficiaries had longer hospice stays than continuous TM beneficiaries (48.3 vs 43.8 days). Compared with continuous TM, continuous MA beneficiaries were more likely to receive hospice at home (1.93 percentage points [pp]; 95% CI, 1.40-2.45 pp; P < .001), while those who switched from MA to TM were more likely to receive hospice in nursing homes (2.45 pp; 95% CI, 1.26-3.63 pp; P < .001), particularly among dual Medicare-Medicaid enrollees (6.01 pp; 95% CI, 2.80 to 9.21 pp; P < .001).

CONCLUSIONS AND RELEVANCE: In this cohort study of Medicare decedents with advanced cancers, continuous MA enrollees were most likely to receive hospice at home, while those who switched from MA to TM more frequently received hospice care in nursing homes. Plan switching near the EOL may reflect access barriers, highlighting the importance of addressing care coordination to improve EOL care.

PMID:41874509 | DOI:10.1001/jamanetworkopen.2026.0755

JAMA Netw Open. 2026 Mar 2;9(3):e263042. doi: 10.1001/jamanetworkopen.2026.3042.

ABSTRACT

IMPORTANCE: The Emergency Severity Index (ESI) is the most widely used triage system in US emergency departments (EDs), but its performance in triaging children presenting with behavioral health symptoms is not well studied.

OBJECTIVE: To assess the frequency of overtriage and undertriage and to identify characteristics associated with both among children presenting to the ED with behavioral health symptoms.

DESIGN, SETTING, AND PARTICIPANTS: This retrospective cross-sectional study was performed in 15 US EDs participating in the Pediatric Emergency Care Applied Research Network (PECARN) Registry. Participants included children and adolescents aged 5 to 17 years presenting to EDs within the PECARN Registry with a behavioral health chief concern from January 1, 2021, to December 31, 2023. Data were analyzed from July 1, 2024, to January 15, 2026.

EXPOSURES: Sociodemographic and clinical characteristics.

MAIN OUTCOMES AND MEASURES: Appropriate triage, overtriage, and undertriage were defined using combinations of first-obtained vital signs, Glasgow Coma Scale, pain score, receipt of emergency medications, distinct resource types used (eg, laboratory tests, imaging studies), and disposition. Multivariable logistic regression assessed characteristics associated with overtriage and undertriage, compared with appropriate triage, adjusting for year and site effects.

RESULTS: A total of 78 411 ED visits by children and adolescents with a behavioral health chief concern (37 328 [47.6%] aged 10-14 years; median age, 14.4 [IQR, 12.4-16.1] years; 47 496 [60.6%] female) were included in the analysis. Of 74 564 visits with nonmissing data, 25 668 (34.4%) were appropriately triaged, 42 589 (57.1%) were overtriaged, and 6307 (8.5%) were undertriaged. The adjusted odds of overtriage were higher for visits by children aged 5 to 9 years (adjusted odds ratio [AOR], 4.43; 95% CI, 4.13-4.76) compared with those aged 10 to 14 years and for visits by non-Hispanic Black (AOR, 1.17; 95% CI, 1.12-1.22) compared with non-Hispanic White patients. The adjusted odds of undertriage were higher for visits by Hispanic patients (AOR, 1.46; 95% CI, 1.31-1.63) and non-Hispanic Black patients (AOR, 1.28; 95% CI, 1.19-1.37) compared with non-Hispanic White patients and for those with Spanish language preference (AOR, 1.31; 95% CI, 1.11-1.54) compared with those preferring English.

CONCLUSIONS AND RELEVANCE: In this cross-sectional study of children presenting to the ED with behavioral health symptoms, overtriage was common, and the likelihood of overtriage and undertriage differed by sociodemographic characteristics. Prospective studies are needed to assess behavioral health triage practices and to design triage systems that allocate resources accurately and equitably.

PMID:41874504 | DOI:10.1001/jamanetworkopen.2026.3042

JAMA Netw Open. 2026 Mar 2;9(3):e263060. doi: 10.1001/jamanetworkopen.2026.3060.

ABSTRACT

IMPORTANCE: Medicaid-enrolled children are entitled to Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefits, which include general and behavioral health (BH) screenings. Adolescents remain among the least likely to receive recommended screenings, and little is known about how screening delivery varies across plans or aligns with plan quality ratings.

OBJECTIVES: To examine trends in general and BH screenings under EPSDT among adolescents aged 12 to 18 years in New York Medicaid managed care and to assess whether screening performance differs by managed care organization (MCO) quality ratings.

DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study used New York Medicaid administrative data from January 2016 to December 2021, including enrollment and claims from the Transformed Medicaid Statistical Information System analytic files. During the study period, reporting of BH screening was voluntary. The study included adolescents aged 12 to 18 years who were continuously enrolled for at least 6 months in a given calendar year. Data analysis was conducted from March 2025 to January 2026.

EXPOSURE: Enrollment as an adolescent in a Medicaid MCO in New York State.

MAIN OUTCOMES AND MEASURES: Claims-based measures of utilization of general and BH screenings consistent with EPSDT services. The primary measures were (1) the percentage of adolescents receiving at least 1 general screening and (2) the percentage receiving at least 1 BH screening during a calendar year. In a supplemental analysis, the correlation between general and BH EPSDT screening rates was tested.

RESULTS: This cross-sectional study included 1 562 342 unique adolescents aged 12 to 18 years enrolled in New York Medicaid from 2016 to 2021 (mean [SD] age, 14.9 [2.0] years; 761 203 [48.7%] female; 7629 [0.5%] American Indian or Alaska Native; 148 576 [9.5%] Asian American or Pacific Islander; 286 003 [18.3%] Black; 204 340 [13.1%] Hispanic; 403 490 [25.8%] White; 512 304 [32.8%] additional groups or missing information). General EPSDT screening rates ranged from 52.5% to 61.0% annually, with the lowest rate observed in 2020 during the onset of the COVID-19 pandemic. BH screening rates increased over time, from 7.7% in 2016 to 21.2% in 2021, but remained substantially lower than general EPSDT screening rates, reaching only about one-third of general screening rates. Screening rates were highest for mid-adolescents (ages 14-16 years) and lowest for ages 12 and 18 years. Across MCOs, general screening rates were relatively consistent, whereas BH screening rates varied widely, with only moderate correlation between the 2 screening types at the plan level (Pearson r = 0.47). BH performance showed little alignment with state-assigned MCO quality ratings.

CONCLUSIONS AND RELEVANCE: In this cross-sectional study of adolescents in New York Medicaid from 2016 to 2021, BH screening rates remained far lower than general EPSDT screening rates, with wide variation across MCOs and limited alignment with state-assigned MCO quality ratings. These gaps may reflect long-standing structural challenges, including previously voluntary reporting of adolescent depression screening by the Centers for Medicare & Medicaid Services under the Mandatory Core Set of Behavioral Health Measures for Medicaid and Children’s Health Insurance Program. Incorporating now-mandatory BH measures into MCO performance benchmarks could increase adolescent BH screening rates, strengthen accountability, support earlier detection of mental health conditions, and reduce variation in preventive care delivery both in New York and nationwide.

PMID:41874503 | DOI:10.1001/jamanetworkopen.2026.3060

JAMA Netw Open. 2026 Mar 2;9(3):e263161. doi: 10.1001/jamanetworkopen.2026.3161.

ABSTRACT

IMPORTANCE: Exploring the relationship between moral distress and occupational burnout is necessary to understand the association between these constructs.

OBJECTIVE: To evaluate moral distress among physicians and US workers, and to explore the association of moral distress with burnout, intent to leave (ITL) current position, and intent to reduce clinical work hours (ITR).

DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional national survey study included physicians from all specialties and a probability-based sample of employed nonphysicians. Participants were aged 29 to 65 years. Data were collected between October 19, 2023, and March 5, 2024. Data were analyzed from June 30 to October 20, 2025.

MAIN OUTCOMES AND MEASURES: Moral distress was measured using the Moral Distress Thermometer (MDT, range 0-10), with a high level of moral distress defined by a score of 4 or higher. Burnout was measured using the complete Maslach Burnout Inventory (MBI). Professional fulfillment was measured using the Stanford Professional Fulfillment Index. ITL and ITR were measured using a standardized item with response options of none, slight, moderate, likely, and definitely.

RESULTS: This survey study included 5741 physicians and 3501 nonphysician US workers. The median (IQR) age of physicians was 53 (44-62), and included 3262 men (58.0%), 2255 women (40.1%), and 107 individuals who responded other (1.9%). The mean (SD) moral distress score for physicians was 3.29 (2.81), with 2243 (39.1%) reporting a high level of moral distress (4 or more considered high). On multivariable analysis, women physicians had higher odds of moral distress (OR, 1.29; 95% CI, 1.12-1.48). Compared with internal medicine subspecialists, emergency medicine physicians (OR, 3.16; 95% CI, 2.27-4.4) and general internal medicine physicians (OR, 1.92; 95% CI, 1.42-2.59) were more likely to report high levels of moral distress. Mean emotional exhaustion and depersonalization scores, as well as the proportion of physicians with burnout, were higher with each 1-point increase in moral distress score. The overall correlation between the emotional exhaustion score and moral distress score was R = 0.55 (P < .001) while the correlation between the depersonalization score and moral distress score was R = 0.50 (P < .001). Additionally, 1068 of 3477 physicians (30.7%) with a moral distress score less than 4 had burnout symptoms compared with 1675 of 2231 physicians (75.1%) with scores of 4 or more (P < .001). The prevalence of ITL and ITR was higher for each 1-point increase in moral distress score. For example, 619 of 3404 physicians (18.2%) with low moral distress reported ITL within 24 months compared with 748 of 2171 (34.5%) among those with high moral distress (P < .001). Compared with other US workers, physicians had markedly higher odds of experiencing moral distress (OR, 4.40; 95% CI, 3.84-5.06).

CONCLUSION AND RELEVANCE: In this survey study, moral distress was common among physicians and experienced at higher rates than the general US working population. Understanding the differences between moral distress and burnout may allow organizations to more effectively implement interventions to address both concerns among clinicians.

PMID:41874502 | DOI:10.1001/jamanetworkopen.2026.3161

Pract Radiat Oncol. 2025 Oct 18:S1879-8500(25)00224-3. doi: 10.1016/j.prro.2025.09.001. Online ahead of print.

ABSTRACT

PURPOSE: The recently published results of the National Surgical Adjuvant Breast and Bowel Project B51 trial suggest that regional nodal irradiation may be safely omitted in patients with cT1-3N1 breast cancer treated with either lumpectomy or mastectomy, and achieve a pathologic complete response (pCR) in the regional nodes. Of note, almost 80% of patients on the trial demonstrated breast pCR. The goal of our study was to compare clinical outcomes between patients with breast pCR versus not.

METHODS AND MATERIALS: We included all patients treated at a single institution between 2010 and 2021 with cT1-3N1 breast cancer (pathologically proven via fine needle aspiration) who completed neoadjuvant chemotherapy and had axillary nodal pCR. Patients could undergo breast-conserving surgery or mastectomy. Univariate and multivariate logistic models were used to identify factors associated with breast pCR. Cox proportional hazard model was used to find independent prognostic variables associated with disease-free survival (DFS).

RESULTS: We identified 124 patients meeting eligibility criteria. Of those, 72 patients (58%) achieved a breast pCR. On multivariate analysis, patients with human epidermal growth factor receptor (HER2)-positive breast cancer were more likely to develop breast pCR than patients with HER2-negative disease (odds ratio = 15.3; CI, 2.9-156.6; P = .001). At a median follow-up of 5 years, our study showed an overall low rate of local recurrence or distant metastasis with 5-year DFS of 92.3%. There was a numerically higher disease recurrence rate in patients without a breast pCR compared to those with a breast pCR, though this difference was not statistically significant (4.2% vs 12%; hazard ratio = 3.41; 95% CI, 0.53-22.1; P = .2).

CONCLUSIONS: Our study showed that of the 124 patients who had pCR in the nodes, only 58% had a pCR in the breast, which is lower than the 80% rate seen in National Surgical Adjuvant Breast and Bowel Project B51. While our study found no significant difference in 5-year DFS between those with breast pCR versus not, given that patients with ER/PR+/HER2- disease are less likely to achieve breast pCR and tend to recur at later timepoints, further research is needed to evaluate the benefit of regional nodal irradiation in patients with a pCR in the axilla without a pCR in the breast.

PMID:41874497 | DOI:10.1016/j.prro.2025.09.001