Nevin Manimala

J Med Internet Res. 2026 Mar 25;28:e79363. doi: 10.2196/79363.

ABSTRACT

BACKGROUND: Stroke is a leading cause of long-term upper limb disability, severely impacting patients’ independence and quality of life. Robot-assisted therapy (RAT) has emerged as a promising, high-intensity rehabilitation alternative. However, conclusions from existing systematic reviews on its efficacy are inconsistent and often lack a holistic framework, limiting their use for guiding personalized clinical decisions.

OBJECTIVE: This study aims to systematically synthesize recent evidence on RAT for upper limb rehabilitation after stroke. Guided by the International Classification of Functioning, Disability and Health framework, it moves beyond singular outcomes to provide a multidimensional evaluation across body function, activity, and participation levels. The review aims to provide stratified guidance for clinical decision-making based on patient- and intervention-specific characteristics, thereby supporting evidence-based practice and informing future research.

METHODS: This study included systematic reviews and meta-analyses published from January 1, 2019, to December 26, 2025, comparing RAT with conventional therapy for upper limb rehabilitation after stroke. Overall, 6 databases, including PubMed, Web of Science, and Embase, were searched. Two reviewers (XZ and LZ) independently performed study selection, data extraction, and quality assessment using the AMSTAR 2 tool. The synthesis integrated outcome measures and subgroup analyses derived from the included studies.

RESULTS: This umbrella review included 21 meta-analyses encompassing 535 randomized controlled trials and 27,598 patients across acute, subacute, and chronic stroke stages. According to AMSTAR 2, 17 reviews were high quality, 3 moderate, and 1 critically low. The synthesis demonstrated that RAT was superior in improving upper limb motor function, but no statistically significant advantages were observed in activities of daily living compared to conventional therapy. Subgroup analyses revealed that treatment effects were influenced by stroke stage, upper limb motor impairment level, and robot type.

CONCLUSIONS: RAT is an effective intervention for improving upper limb motor function after stroke. However, its benefits are primarily observed at the level of body function, with limited evidence for long-term maintenance. The current evidence is constrained by significant outcome heterogeneity and methodological limitations inherent to umbrella reviews. Future research should validate these findings in broader clinical practice, focus on translating functional gains into sustained improvements in daily activities and participation, and include cost-effectiveness evaluations.

TRIAL REGISTRATION: PROSPERO CRD42024497183; https://www.crd.york.ac.uk/PROSPERO/view/CRD42024497183.

PMID:41879816 | DOI:10.2196/79363

Am J Clin Oncol. 2026 Mar 25. doi: 10.1097/COC.0000000000001321. Online ahead of print.

ABSTRACT

OBJECTIVES: Solitary plasmacytoma is a rare plasma cell neoplasm with varying outcomes. This large IRB-approved retrospective analysis used the National Cancer Database (NCDB) to assess prognostic factors, treatment patterns, and overall survival (OS) among patients treated at Commission on Cancer-accredited facilities in the United States.

METHODS: Plasmacytoma patients (N=9427) from 2004 to 2020 were identified using the NCDB, excluding multiple myeloma. Descriptive statistics, Kaplan-Meier curves, and multivariate Cox regression analysis were used to evaluate survival outcomes by primary site, radiation dosage, and treatment modality. SAS version 9.4 was used to analyze the data.

RESULTS: Among 9427 patients, solitary plasmacytoma of bone (P-Bone) comprised 73% and extramedullary plasmacytoma (P-EM) 27%. Median OS was 106 months for P-Bone versus 146 months for P-EM (P<0.0001). Combined radiation therapy and surgery achieved the longest median OS (181 mo) versus surgery alone (137 mo) and radiation alone (116 mo; P<0.0001). OS increased with higher radiation dose: <35 Gy (46.6 mo) to ≥50 Gy (176.4 mo; P<0.0001). Among P-Bone sites, skull/mandible lesions showed the best outcomes (122.3 mo). Radiation doses of 45 to 49.9 Gy predominated across most sites.

CONCLUSIONS: This real-world study analyzes treatment patterns and overall survival in the largest plasmacytoma database to date. Combined surgery and radiation therapy show improved survival outcomes, emphasizing the need for personalized treatment approaches and the strength of combined modality therapy. Considering the primary bone site and radiation dosage aids prognostic assessment and treatment decision-making, contributing to plasmacytoma management and personalized care.

PMID:41879814 | DOI:10.1097/COC.0000000000001321

Glob Health Action. 2026 Dec;19(1):2647528. doi: 10.1080/16549716.2026.2647528. Epub 2026 Mar 25.

ABSTRACT

All Gulf Cooperation Council (GCC) countries have a multi-payer healthcare system that comprises governmental health coverage (GHC), funded by the government, and private health insurance (PHI), mainly sponsored by employers and purchased by individuals. Both are expected to influence healthcare utilization and contribute to system efficiency and patient well-being. This systematic review explored the determinants of PHI uptake and its association with healthcare service utilization in the presence of GHC in GCC countries. We systematically searched CINAHL, PubMed, Scopus, Web of Science, and Cochrane Library for peer-reviewed studies published between January 2012 and October 2022. Study quality was assessed using the Critical Appraisal Skills Programme (CASP) checklists for both quantitative and qualitative studies, following PRISMA guidelines. Twenty-six studies met the inclusion criteria. Determinants of PHI uptake were mapped to Andersen’s Behavioral Model of Health Services Use (BMHSU) and categorized into (1) predisposing factors (sex, age, marital status, and education), (2) enabling factors (employment/income and health system-related factors such as access and perceived service quality), and (3) need factors (health status, including chronic noncommunicable diseases). PHI uptake was positively associated with being male, married, highly educated, employed with a high income, and having chronic diseases. PHI was positively associated with healthcare utilization, particularly routine check-ups, preventive services, and the use of prescribed medicines. In GCC countries, PHI uptake is influenced by sociodemographic and socioeconomic characteristics, health status, and perceived service quality. PHI is also associated with higher healthcare utilization, underlining the need for evidence-informed policies that enhance equity and expand coverage.

PMID:41879796 | DOI:10.1080/16549716.2026.2647528

JAMA Netw Open. 2026 Mar 2;9(3):e262103. doi: 10.1001/jamanetworkopen.2026.2103.

ABSTRACT

IMPORTANCE: Patients with cancer face an increased risk of Clostridioides difficile infection (CDI) due to several factors, including chemotherapy and repeated health care exposures. However, recent national-level data characterizing the prevalence of CDI, associated clinical outcomes, and resource utilization in this population remain limited.

OBJECTIVE: To characterize the hospitalization-level prevalence, clinical outcomes, and health care resource utilization associated with CDI among hospitalized patients with cancer in the US.

DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study used data from the National Inpatient Sample, a nationally representative database, to identify hospitalizations among adults with a diagnosis of cancer between January 1, 2016, and December 31, 2022. Hospitalizations with CDI were identified using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes. Data were analyzed from May to June 2025.

EXPOSURES: Presence of CDI as a primary or secondary diagnosis during the index hospitalization.

MAIN OUTCOMES AND MEASURES: The primary outcome was in-hospital, all-cause mortality. Secondary outcomes included need for kidney replacement therapy, mechanical ventilation, vasopressor support, and colonoscopy. Multivariable logistic regression was used to adjust for demographics, comorbidities, cancer type, and hospital characteristics.

RESULTS: Of 32 083 671 cancer-related hospitalizations (overall study population mean [SD] patient age, 69.4 [13.9] years; 16 050 025 [50.0%] male), 450 360 (1.4%) involved a diagnosis of CDI. Compared with hospitalizations without CDI, those with CDI involved older patients, a higher proportion of women, and higher prevalence of hematologic cancers, cirrhosis, solid organ transplant, bone marrow transplant, chronic kidney disease, and inflammatory bowel disease. Patients with CDI infection had higher in-hospital mortality (7.3% vs 4.5%; adjusted odds ratio [aOR], 1.62; 95% CI, 1.58-1.67) and greater use of critical care interventions. CDI was associated with higher rates of critical care interventions, including kidey replacement therapy (44.3 vs 20.4 per 1000 hospitalizations; aOR, 2.00; 95% CI, 1.92-2.08; P < .001), mechanical ventilation (68.1 vs 35.6 per 1000 hospitalizations; aOR, 1.89; 95% CI, 1.84-1.95; P < .001), and vasopressor use (25.6 vs 11.5 per 1000 hospitalizations; aOR, 2.11; 95% CI, 2.00-2.24; P < .001). Mortality among patients with CDI varied geographically, ranging from 6.4% (95% CI, 6.2%-6.5%) in the Midwest to 8.5% (95% CI, 8.3%-8.7%) in the Northeast.

CONCLUSIONS AND RELEVANCE: In this cross-sectional study of US oncologic hospitalizations, CDI occurred in 1 in 70 cancer-related hospitalizations and was associated with significantly increased mortality and resource utilization. These findings underscore the need for targeted prevention and early intervention strategies in this vulnerable population.

PMID:41879784 | DOI:10.1001/jamanetworkopen.2026.2103

JAMA Netw Open. 2026 Mar 2;9(3):e262443. doi: 10.1001/jamanetworkopen.2026.2443.

ABSTRACT

IMPORTANCE: Large language models (LLMs) are increasingly being applied to analyze clinical data, primarily clinical text, with an increasing emphasis on integration in health care. However, the use of LLMs in pediatric care remains underexplored.

OBJECTIVE: To map the emerging literature on LLM use in pediatrics involving clinical text and identify evidence gaps and future directions for implementation and evaluation.

EVIDENCE REVIEW: PubMed/MEDLINE, Embase, Web of Science, Scopus, and preprint servers were searched for English-language original research published from January 1, 2020, to July 1, 2025. Included studies used modern transformer-based LLMs with pediatric clinical text as input. Two reviewers independently screened studies using predefined criteria. Data were extracted by one reviewer and verified by another. Findings were descriptively synthesized, and adherence to the Minimum Information for Medical AI Reporting (MINIMAR) standards was assessed.

FINDINGS: The review included 40 studies published between 2023 and 2025. Twenty-three studies were conducted in the US, and all were retrospective observational studies using clinical data from sources such as electronic health records. Participant sample sizes ranged from 10 to 172 683. Although all pediatric age subgroups were represented, early childhood populations (aged 0-5 years) were underrepresented. The most common LLM clinical applications were diagnostic decision support in 24 studies (60.0%) and treatment planning in 7 studies (17.5%). Although all 40 studies conducted clinical evaluation of LLMs and 30 included discussions of ethics or data privacy, 39 studies (97.5%) did not meet full MINIMAR standards, 34 (85.0%) did not report use of Health Insurance Portability and Accountability Act-compliant models, and 30 (75.0%) lacked fine-tuning for pediatric-specific data. Among 33 studies assessing model performance against human annotations, 10 (30.3%) did not include clinicians as annotators; among 26 studies with multiple annotators, only 9 (34.6%) reported interannotator agreement statistics.

CONCLUSIONS AND RELEVANCE: This scoping review found that diagnostic decision support and treatment planning were commonly proposed applications of LLMs in pediatrics. However, gaps in scientific rigor and limited use of pediatric-specific data may hinder their safe and effective implementation in pediatrics. Future studies should use standardized evaluation and reporting methods, increase clinician involvement, and expand research to underrepresented ages and clinical applications.

PMID:41879783 | DOI:10.1001/jamanetworkopen.2026.2443

JAMA Netw Open. 2026 Mar 2;9(3):e263050. doi: 10.1001/jamanetworkopen.2026.3050.

ABSTRACT

IMPORTANCE: Although buprenorphine is highly effective at preventing overdose, access is limited in rural areas. Rural primary care is a critical site to expand access; prescribing support tailored for this setting is urgently needed.

OBJECTIVE: To test the feasibility and preliminary effectiveness of a brief buprenorphine prescribing support program (BPSP) tailored for rural primary care professionals (PCPs).

DESIGN, SETTING, AND PARTICIPANTS: This cluster randomized pilot clinical trial compared 27 Ohio community health centers with 63 PCPs (10 physicians, 50 nurse practitioners, and 3 physician assistants) receiving the support program at baseline and immediately after the intervention with those receiving only copies of the American Society of Addiction Medicine’s buprenorphine prescribing guidelines. Data were collected from July 25, 2024, to February 28, 2025.

INTERVENTIONS: The BPSP is a brief, hour-long, asynchronous and online training program, followed by an optional, live booster session, that provides clinical skills on buprenorphine prescribing, addresses misinformation on the safety of buprenorphine, and addresses stigma toward buprenorphine. Health centers were randomized with 2 centers allocated to the intervention for every 1 allocated to the control condition.

MAIN OUTCOMES AND MEASURES: Primary implementation outcomes were feasibility (measured via the 4-item Feasibility of Intervention Measure [scale of 1 to 5, with higher scores indicating greater feasibility]), acceptability (measured via the 4-item Acceptability of Intervention Measure [scale of 1 to 5, with lhigher scores indicating greater acceptability]), and appropriateness (measured via the 4-item Intervention Appropriateness Measure [scale of 1 to 5, with higher scores indicating greater appropriateness]) of the BPSP; willingness to treat opioid use disorder (OUD) in primary care (using a measure developed and tested with a different sample of PCPs); and likelihood of prescribing buprenorphine in the next 6 months (measured via a 5-point Likert scale ranging from 1.00 [extremely unlikely] to 5.00 [extremely likely]).

RESULTS: Of the 63 participating PCPs, 48 participants were allocated to the intervention condition and 15 to the control condition (49 female [78%]; mean [SD] age, 45.5 [11.4] years). Forty-nine participants (78%) practiced in rural areas and 10 (16%) had ever prescribed buprenorphine. Participants receiving the BPSP rated it as highly feasible (median score, 4.25 [IQR, 4.00-5.00]), acceptable (median score, 4.88 of 5.00 [IQR, 4.00-5.00]), and appropriate (median score, 5.00 of 5.00 [IQR, 4.00-5.00]). Participants receiving the BPSP had significantly higher willingness to treat OUD; 86% of rank comparisons improved post intervention. Intention to prescribe buprenorphine in the next 6 months also significantly increased; 98% of rank comparisons improved post intervention. Participants who completed the BPSP showed significant improvements in having correct information about buprenorphine, had greater confidence treating addiction and prescribing buprenorphine, and had lower stigma and greater empathy toward patients with OUD.

CONCLUSIONS AND RELEVANCE: In this cluster randomized clinical trial of the BPSF, brief prescribing support was feasible, acceptable, and appropriate for implementation in rural primary care, and intentions to prescribe buprenorphine increased. A larger trial is needed to confirm preliminary findings.

TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT05505227.

PMID:41879782 | DOI:10.1001/jamanetworkopen.2026.3050

JAMA Netw Open. 2026 Mar 2;9(3):e263410. doi: 10.1001/jamanetworkopen.2026.3410.

ABSTRACT

IMPORTANCE: Despite safety warnings, antipsychotics remain commonly prescribed to older adults, particularly those with dementia, and for off-label indications. However, little is known about how prescribing patterns vary by clinician type over time.

OBJECTIVE: To examine trends in antipsychotic prescribing by clinician type among Medicare beneficiaries from 2013 to 2023.

DESIGN, SETTING, AND PARTICIPANTS: This repeated cross-sectional study used the Medicare Part D Prescribers by Provider and Drug dataset from 2013 to 2023. Participants included Medicare beneficiaries enrolled in Medicare Part D. Analyses were performed between November 2024 and June 2025.

EXPOSURE: Prescribing clinician type, categorized as psychiatrist, primary care physician (PCP), advanced practice registered nurse (APRN) or physician assistant (PA), or other physician.

MAIN OUTCOMES AND MEASURES: Annual antipsychotic prescription claims, the proportion of claims by clinician type, the number of prescribing clinicians, and the mean number of claims per clinician.

RESULTS: From 2013 to 2023, annual antipsychotic prescription claims decreased from 10.8 million to 7.8 million for psychiatrists (average annual percentage change [AAPC], -3.2% [95% CI, -3.7% to -2.7%]; P < .001) and from 7.4 million to 5.7 million for PCPs (AAPC, -2.6% [95% CI, -3.2% to -2.3%]; P < .001). In contrast, claims prescribed by APRNs or PAs more than tripled from 2013 to 2023, increasing from 3.1 million to 9.5 million (AAPC, 11.8% [95% CI, 10.9%-12.7%]; P < .001). The proportion of prescriptions decreased for psychiatrists (48.4% to 32.4%) and PCPs (33.0% to 23.8%) but increased for APRNs and PAs (13.8% to 39.6%) from 2013 to 2023. These shifts were associated primarily with the expanding number of prescribing APRNs and PAs rather than an increase in the mean number of claims per clinician. Although trends were observed in both rural and urban areas, rural areas experienced larger shifts from PCPs to APRNs and PAs, whereas urban areas experienced larger shifts from psychiatrists to APRNs and PAs.

CONCLUSIONS AND RELEVANCE: In this cross-sectional study of Medicare Part D data from 2013 to 2023, antipsychotic prescribing shifted from psychiatrists and PCPs to APRNs and PAs, reflecting growth in nonphysician prescribers. These findings suggest evolving roles in antipsychotic medication management and highlight the need for appropriate training for the full range of clinician types who prescribe these medications to Medicare enrollees.

PMID:41879781 | DOI:10.1001/jamanetworkopen.2026.3410

JAMA Netw Open. 2026 Mar 2;9(3):e263439. doi: 10.1001/jamanetworkopen.2026.3439.

ABSTRACT

IMPORTANCE: Patient-directed discharge (PDD), when patients leave the hospital prior to completing recommended medical treatment, is associated with increased morbidity and mortality and occurs in 10% to 20% of hospitalizations for patients with opioid use disorder (OUD). Understanding risk factors associated with PDD is essential to improving outcomes for this population.

OBJECTIVE: To investigate whether hospitalized patients with OUD who received higher doses of methadone during the first 24, 48, and 72 hours after first contact with the emergency department had decreased odds of PDD.

DESIGN, SETTING, AND PARTICIPANTS: This retrospective observational cohort study was conducted at a single academic health center in the northeastern US during the fentanyl era (July 1, 2019, to June 30, 2022). Hospitalized adults with OUD and without methadone listed in their medication history who received methadone during the first 72 hours were included. Data were analyzed from April 2025 through February 2026.

EXPOSURES: Cumulative dose of methadone received for patients 24, 48, and 72 hours after initial evaluation in the emergency department.

MAIN OUTCOMES AND MEASURES: PDD by 48, 72, or 96 hours or ever, as indicated by discharge disposition in the patient electronic health record.

RESULTS: A total of 554 patients were included in the study. For analysis, participants were separated into cohorts based on cumulative dose by 24 hours (325 patients), 48 hours (488 patients), and 72 hours (454 patients) after presentation to the emergency department, with the main analysis among patients in the 24-hour cohort. Among 325 patients (184 male [56.6%]; median [IQR] age, 49.0 [36.0-59.0] years) receiving methadone within 24 hours of presentation to the emergency department, the incidence of PDD was 45 patients (13.8%). In an adjusted logistic regression model, each additional 10 mg of methadone in the first 24 hours was associated with lower odds of PDD (adjusted odds ratio [aOR], 0.71; 95% CI, 0.44-0.98) at 48 hours. Results were similar for PDD at 72 hours (aOR, 0.68; 95% CI, 0.50-0.85), 96 hours (aOR, 0.72; 95% CI, 0.56-0.88), or ever (aOR, 0.79; 95% CI, 0.67-0.91) in the 24-hour cohort and qualitatively similar but with smaller decreases in odds or nonsignificant outcomes for cumulative methadone dose in the 48-hour cohort (eg, PDD at 96 hours: aOR, 0.91; 95% CI, 0.82-0.99) and nonsignificant outcomes in the 72-hour cohort (eg, PDD at 96 hours: aOR, 0.98; 95% CI, 0.89-1.06).

CONCLUSIONS AND RELEVANCE: In this study, higher cumulative doses of methadone during the first 48 hours of care were associated with substantial reductions in the incidence of PDD. These findings suggest that early and adequate treatment of withdrawal with methadone may be associated with reduced PDD among hospitalized patients with OUD in the fentanyl era.

PMID:41879780 | DOI:10.1001/jamanetworkopen.2026.3439

J Diabetes Investig. 2026 Mar 25. doi: 10.1111/jdi.70268. Online ahead of print.

ABSTRACT

AIMS: To quantify the risk of cardiovascular disease (CVD) and all-cause mortality associated with diabetic foot ulcer (DFU)-related amputation using a large-scale, nationally representative cohort.

MATERIALS AND METHODS: This longitudinal study included individuals with diabetes who underwent standardized national health checkups between 2009 and 2012, with follow-up data obtained from the Korean National Health Insurance Service claims database. CVD was defined as an incident myocardial infarction or stroke occurring after the index health checkup. Cox proportional hazards models were used to estimate the hazard ratios (HRs) for CVD and mortality in individuals with DFU-related amputation compared with those with diabetes but without amputation.

RESULTS: Among 1,229,689 individuals with diabetes, 1,486 (0.12%) had a DFU-related amputation at baseline. The median follow-up was 8.2 years in the non-amputation group and 6.7 years in the DFU-related amputation group. People with DFU-related amputation had a significantly higher incidence rate of CVD compared with those without DFU-related amputation (32.6 vs. 11.0 per 1000 person-years) with a HR of 1.9 (95% CI 1.6-2.1). The HRs for myocardial infarction and stroke were 2.2 (95% CI 1.9-2.6) and 1.6 (95% CI 1.4-1.8), respectively. All-cause mortality significantly increased in people with DFU-related amputation compared with those without, with an HR of 2.1 (95% CI 1.9-2.3).

CONCLUSIONS: In this nationwide population-based cohort, DFU-related amputation was associated with nearly a twofold increased risk of cardiovascular events and mortality. These findings underscore the importance of comprehensive cardiovascular risk assessment and management in patients with diabetic foot complications.

PMID:41879777 | DOI:10.1111/jdi.70268

Psychol Rep. 2026 Mar 25:332941261438074. doi: 10.1177/00332941261438074. Online ahead of print.

ABSTRACT

Long-term reactivated memories undergo a time-dependent reconsolidation process during which they are susceptible to modulation. We report the results of an experiment examining the effect of multiple reminder treatments on reconsolidation of a long-term memory. Participants were trained on a procedural finger tapping task and were either reminded of that training 5 days later or not, immediately prior to learning a new tapping sequence. An additional group was given a reminder treatment of original learning on each of the interim days. Contrary to our hypothesis, results indicate that multiple reminder treatments rendered the training memory significantly more susceptible to disruption in comparison to controls that did not receive any reminders of original learning prior to learning the new motor sequence.

PMID:41879773 | DOI:10.1177/00332941261438074