Category: Nevin Manimala

South Med J. 2025 Sep;118(9):614-617. doi: 10.14423/SMJ.0000000000001873.

ABSTRACT

OBJECTIVE: Extreme temperatures negatively impact pulmonary function. This study explored whether the variability in ambient temperatures across disparate geographic regions in the United States was associated with differences in hospital outcomes for patients admitted with chronic obstructive pulmonary disease (COPD).

METHODS: Using the 2016-2019 National Inpatient Sample database, we compared adults hospitalized with COPD in the US Northeast with those in the US South. We conducted multivariable regression analyses to study outcomes, including mortality, resource utilization, and posthospital discharge disposition.

RESULTS: From 2016 to 2019, 463,830 (30.1%) patients were admitted with COPD in the Northeast and 1,078,930 (69.9%) in the South. The lowest hospitalization rates for COPD were observed in both regions during the hottest months (July and August). Those in the Northeast had higher adjusted odds of in-hospital mortality (adjusted odds ratio: 1.1 [95% confidence interval {CI} 1.0-1.2]; P = 0.03) and a lower likelihood of being discharged to home after the hospitalizations (adjusted odds ratio: 0.63 [95% CI 0.61-0.65]; P < 0.01]) compared with patients hospitalized in the South. Patients in the Northeast had longer hospital stays (adjusted mean difference: +0.19 days; 95% CI 0.13-0.25; P < 0.01) and incurred greater hospital charges compared with patients in the South (adjusted mean difference: $3728; 95% CI 1840-5616; P < 0.01).

CONCLUSIONS: Patients hospitalized with COPD in the Northeast had worse clinical outcomes and greater resource utilization than in the South. These findings, coupled with the higher admission rates during colder months, raise questions about the influence of colder ambient temperatures on COPD exacerbations.

PMID:41032272 | DOI:10.14423/SMJ.0000000000001873

South Med J. 2025 Sep;118(9):602-605. doi: 10.14423/SMJ.0000000000001874.

ABSTRACT

OBJECTIVES: Concussions are one of the most frequent pediatric injuries, especially for high school athletes. Many of the psychological sequalae from concussions go unnoticed and undertreated particularly in the rural setting. There is limited research on optimizing recovery for these patients; however, newer studies are beginning to show the utilization of deep breathing exercises. In this study, we evaluated the effectiveness of self-administered relaxation techniques for postconcussive mood symptoms in an Appalachian population.

METHODS: Patients’ charts (N = 308) from a rural specialty concussion clinic between September 2020 and May 2023 underwent a review. Eligible patients included those who completed the Post-Concussion Symptom Scale (PCSS), Patient Health Questionnaire, and Generalized Anxiety Disorder scale (GAD-7) during their initial intake visit. Patients who suffered from at least mild to moderate depression and/or anxiety were educated on self-administered relaxation techniques, which consisted of 15 minutes of deep breathing exercises to be performed nightly. Their mood symptoms were reassessed, after monitoring patient compliance with breathing exercises, via a 4-point Likert scale at their follow-up appointment (average 13.5 days). The data were grouped based on the patient’s compliance (good vs limited) with their respective score improvement and analyzed via paired t tests. Good compliance consisted of performing the breathing exercises “most of the time” and the limited compliance group performed exercises “some of the time, seldom, or rarely/none.” The second part of the analysis investigated if there were any significant difference in improvements between the good and limited compliance groups using unpaired t test statistics.

RESULTS: The good compliance group experienced a significant improvement in Patient Health Questionnaire (7.11, P < 0.01), GAD (6.33, P < 0.01), and PCSS (24.33, P < 0.01) scores at follow-up. The limited compliance group only had a significant improvement in GAD (2.14, P = 0.025) and PCSS (29.77, P < 0.01). There was a significant difference in anxiety improvement between good and limited compliance groups by 4.19 points as assessed by the GAD scale (P < 0.01).

CONCLUSIONS: Self-administered deep breathing exercises are a cost-free, practical, and safe intervention that may benefit patients with persistent mood symptoms in the concussion rehabilitation process, particularly in resource scarce areas in Appalachia.

PMID:41032270 | DOI:10.14423/SMJ.0000000000001874

South Med J. 2025 Sep;118(9):596-601. doi: 10.14423/SMJ.0000000000001868.

ABSTRACT

OBJECTIVE: Incidental lesions identified clinically or on imaging are diagnostically challenging. The workup for these lesions is not well established. We investigated diagnostic modalities used at our institutions for undiagnosed lesions and the timeline from intake to biopsy and resultant diagnoses.

METHODS: We retrospectively analyzed data from all 3 Mayo Clinic sites (Arizona, Florida, and Minnesota) between November 1, 2018 and July 31, 2022. We evaluated the frequency of the biopsy technique used (if any) and how often the resultant diagnosis was malignant, benign, or inconclusive. The turnaround time from intake to biopsy and final diagnosis also was evaluated.

RESULTS: Of 93 patients with an undiagnosed lesion, 54 (58%) underwent biopsy; most patients underwent a single biopsy (n = 42, 77%), and 12 (23%) had two or more biopsies. Unbiopsied patients were diagnosed as having benign lesions according to imaging or had follow-up imaging. Of the 54 patients biopsied, 38 (70%) biopsies were obtained via fine-needle aspiration. Biopsy results were malignant for 34 patients (63%), benign for 14 (26%), and inconclusive for six (11%). Most patients were seen within 9 days of their initial contact (69/93, 74%), underwent biopsy within 20 days of seeing the physician (40/54, 74%), and had a final diagnosis within 30 days of the initial visit (72/93, 77%).

CONCLUSIONS: Our findings can help clinicians dispel the misconception that most undiagnosed lesions are malignant. Our findings also may help clinicians determine the appropriate workup for undiagnosed lesions. Further research is recommended to guide clinicians on the best sampling methodologies to obtain the highest yield of tissue for analysis. Dedicated patient workflows can help expedite diagnosis.

PMID:41032269 | DOI:10.14423/SMJ.0000000000001868

South Med J. 2025 Sep;118(9):589-595. doi: 10.14423/SMJ.0000000000001878.

ABSTRACT

OBJECTIVES: Despite the common performance of thoracentesis, predicting risk for adverse outcomes and abnormal postprocedural findings remains difficult. Although guidelines and experts have suggested that routine postprocedure imaging has low yield, compliance with these guidelines has not been well studied. In addition, previous studies have shown that pleural effusions are associated with high short-term mortality rates, longer hospitalizations, and higher readmission rates, increasing the importance of systematic study of procedural results. We aimed to determine the rate of imaging abnormalities, the utility of routine postprocedure imaging, and health outcomes for hospitalized patients requiring thoracentesis.

METHODS: An epidemiologic description including adult inpatients at one academic medical center who underwent thoracentesis outside of radiology-specialty procedural areas during a 2-year period. Charts were individually reviewed for data extraction.

RESULTS: In total, 425 thoracentesis procedures in 329 patients were included. A chest x-ray was obtained after 80.9% of procedures. Postprocedure imaging abnormalities included pneumothorax (8.0%), hemothorax (1.6%), reexpansion pulmonary edema (7.8%), and pneumothorax ex vacuo (4.7%). The average hospital length of stay was 13 days, and 15% required mechanical ventilation during their hospitalization. Fifty-five percent of participants were discharged home, 22.8% to a medical facility, 14.4% transitioned to hospice care, and 8.1% died during hospitalization.

CONCLUSIONS: Overall, approximately 20% of patients required clinical reassessment or intervention following thoracentesis. The findings confirm a high rate of secondary morbidity, in-hospital mortality, and long length of stay for hospitalized patients undergoing thoracentesis. The requirement for inpatient thoracentesis represents an opportunity to address end-of-life issues and to identify approaches to optimize resource utilization.

PMID:41032268 | DOI:10.14423/SMJ.0000000000001878

South Med J. 2025 Sep;118(9):585-588. doi: 10.14423/SMJ.0000000000001867.

ABSTRACT

OBJECTIVES: There has been growing evidence that insurance status is a major indicator of postoperative outcomes, which has been extensively reported in orthopedic procedures such as shoulder and knee arthroplasty. Patients with Medicaid public insurance had increased complications, longer lengths of stay, and increased costs compared with patients who had private insurance when controlling for demographic characteristics. Our study compared the outcomes of patients with Medicaid insurance with those patients with private commercial insurance who have undergone anterior cruciate ligament (ACL) reconstruction. We hypothesized that patients with Medicaid insurance coverage would have worse patient-reported outcomes and complication rates in comparison with a matched cohort of patients with private insurance.

METHODS: Our departmental registry was queried for all patients who underwent primary arthroscopically assisted ACL reconstruction by 10 surgeons in the practice between January 2018 and June 2022 and were at least 2 years out from their surgery. Eligible patients in the matched cohort model were contacted via telephone for consent to participate in this study and questioned about their pain level, return to sport, physical therapy compliance, and any incidence of retear rates or additional procedures in their ipsilateral or contralateral knee. Patients were then compared across insurance types based on Lysholm knee score, as well as the other patient-reported outcomes.

RESULTS: A total of 189 ACL reconstructions were screened during the study period. Fifteen private insurance and 15 Medicaid patients responded to the telephone call and consented to the study. Comparison of the clinical outcomes within the insurance cohorts revealed that there were no significant differences in Lysholm knee scores, pain scores, revision rate, and return to sport. The only significant difference observed was that Medicaid patients had a greater physical therapy compliance rate. Multivariate linear regression analysis revealed that males had the highest odds ratio associated with higher Lysholm scores, but there was no significance observed with any factor.

CONCLUSIONS: Although Medicaid patients did have greater physical therapy attendance, this did not improve their postoperative outcomes, which may suggest that Medicaid status may affect physical therapy effectiveness and can be a confounding variable related to other health disparities. Because the multivariate linear regression analysis did not show any associated factors with poorer postoperative outcomes, this may imply that some demographic factors or insurance status may not be contraindications to ACL reconstruction. Despite the lack of significance, males had a greater likelihood of achieving acceptable Lysholm knee scores based on the multivariate analysis.

PMID:41032267 | DOI:10.14423/SMJ.0000000000001867

South Med J. 2025 Sep;118(9):579-584. doi: 10.14423/SMJ.0000000000001875.

ABSTRACT

OBJECTIVES: An opioid-sparing, multimodal pain (MMP) protocol was initiated at our institution in August 2016 in the Division of Trauma and Acute Care Surgery (TACS). During the next year, the practice was codified into a protocol. This study aims to evaluate the dissemination and impact of MMP.

METHODS: We conducted a single-center retrospective cohort study of all patients admitted to a surgical service from May 2015 to July 2020 to evaluate opioid and nonopioid prescribing for analgesia. The analysis consisted of three populations: patients admitted to the TACS service, the General Surgery subspecialty (GSS) services (excluding TACS), and other surgical department (OSD) services.

RESULTS: Of the 12,010 patients who met the inclusion criteria, 1979 (16.5%) were admitted to the TACS service, 1106 (9.2%) to GSS services, and 8925 (74.3%) to OSD services. Opioid morphine milligram equivalents averaged 38.6 ± 33.3 daily but decreased in all groups over time. Nonopioid adjunctive medications were used in 5932 (49.4%) and increased in all groups after implementation of the protocol (all P < 0.001). After MMP introduction, nonopioid analgesic use increased most rapidly in TACS and the slowest in OSD. Conversely, the average daily morphine milligram equivalents decreased most quickly in TACS (24.4%, P < 0.001), while GSS and OSD services saw a subsequent decrease in opioid use (P = 0.004 and P < 0.001, respectively) as MMP increased.

CONCLUSIONS: Implementation of an MMP protocol by a single division can facilitate the spread of nonopioid adjunctive pain medication use and decrease opioid utilization throughout surgical specialties in a hospital.

PMID:41032266 | DOI:10.14423/SMJ.0000000000001875

ATS Sch. 2025 Oct 1. doi: 10.34197/ats-scholar.2025-0008OC. Online ahead of print.

ABSTRACT

Background: Burnout, characterized by emotional exhaustion, depersonalization, and a reduced sense of personal accomplishment, negatively affects resident physicians and patients. Although burnout is common among intensive care unit (ICU) healthcare workers, data on its impact on resident physicians during their medical ICU (MICU) rotations are limited. Objective: This study aimed to determine the prevalence, key drivers, and mitigating factors for burnout among resident physicians rotating through the MICU. Methods: We conducted a single-center, mixed-methods prospective cohort study in the MICU of an academic quaternary care hospital. Over the course of a 9-month period, we surveyed residents at the end of their MICU rotation and assessed the prevalence of burnout using the Maslach Burnout Inventory, as well as perceived drivers and mitigators of burnout. Focus groups were conducted to further explore internal medicine (IM) residents’ perceptions of drivers and mitigators of MICU-related burnout. Results: Forty-nine residents completed the survey (80% response rate), and 25 IM residents participated in focus groups. The overall burnout prevalence was 88%. Although not statistically significant, higher burnout rates were observed among first-year residents (94% vs. 78%; P = 0.12) and non-IM residents (100% vs. 81%; P = 0.07). Fifty-three percent of residents believed that there was more burnout in the MICU than other ICU rotations. Three themes emerged as drivers of burnout: patient factors (high acuity, adverse outcomes, ethical dilemmas), team and unit dynamics (interdisciplinary tensions, MICU insider-outsider bias), and the clinical learning environment (limited work-life balance, steep learning curve, normalization of burnout). The primary mitigating factors were meaningful patient interactions, supportive team dynamics, structured debriefing, protected time, and focused skill development. Conclusion: Burnout in residents rotating through the MICU is extremely high, higher than the previously reported baseline resident burnout rate of 50-75%. First-year and non-IM residents may be especially vulnerable because of unfamiliarity with the unique team and unit dynamics and clinical learning environment of the MICU (high acuity, high intensity, frequent exposure to dying patients, and unit insider-outsider bias). This study highlights unique factors, which contribute to burnout among MICU residents, that differ from those affecting other critical care staff and could be addressed through targeted interventions.

PMID:41032260 | DOI:10.34197/ats-scholar.2025-0008OC

J Anim Sci. 2025 Oct 1:skaf340. doi: 10.1093/jas/skaf340. Online ahead of print.

ABSTRACT

BACKGROUND: Feed efficiency, nutrient utilization, and methane emission are highly dependent on the gastrointestinal microbiota, implying an influence of these microorganisms on economically important traits (e.g., carcass traits and meat quality). The interaction between microbial composition, diet, and host performance suggests that microbiota-targeted strategies may increase production in livestock animals. However, little is known about this interaction in beef cattle. We aimed to characterize the gastrointestinal microbiota and identify taxa associated with performance phenotypes in Nellore bulls.

RESULTS: We identified 1,268 bacterial and 75 archaeal amplicon sequence variants (ASVs). For both bacteria and archaea, alpha diversity showed significant within-year variation. No statistical differences were found for the Shannon index for bacteria in 2019 versus 2021 or archaea in 2019-2020 and 2021-2022. Except for 2022 (bacteria), no clusters were observed for bacteria or archaea beta diversity across years. Ten different bacteria ASVs were found to affect ribeye area (RA), whereas only five did so for metabolic weight (MW). For archaea, eight ASVs had a significant effect on RA, whereas 15 were found to affect MW. Coefficients of the regression of phenotype on ASV ranged from (± SE, in SD units) -0.40 ± 0.08 (ASV 892, Bacteroidales RF16 spp.) to 0.36 ± 0.11 (ASV 605, Marvinbryantia spp.) for MW, and from -0.72 ± 0.20 (ASV 188, Faecalibacterium spp.) to 0.65 ± 65 (ASV 457, Christensenellaceae R-7 spp.) for RA.

CONCLUSION: Our study revealed significant associations between ASV and traits of economic importance in beef cattle, including carcass, feed efficiency, and morphology, indicating that the microbiome influences animal performance. Further research is needed to elucidate the biological mechanisms behind these associations.

PMID:41032256 | DOI:10.1093/jas/skaf340

Neurol Sci. 2025 Oct 1. doi: 10.1007/s10072-025-08525-9. Online ahead of print.

ABSTRACT

BACKGROUND: Parkinson’s disease (PD) is a progressive neurodegenerative disorder potentially influenced by immune system dysregulation, with the human leukocyte antigen (HLA) system implicated in its pathogenesis. This study aims to evaluate HLA variants’ association with PD risk and clinical attributes.

METHODS: A systematic review and meta-analysis, registered with PROSPERO (CRD420250650550) and adhering to PRISMA Guidelines, was conducted. PubMed, Web of Science, and Scopus were searched from February 2005 to February 2025 for determined keywords. Eligible studies included human-based primary research reporting HLA associations with PD risk or clinical features. Data was extracted on study characteristics, HLA alleles/genotypes, and clinical outcomes. Meta-analysis used fixed-effect models to pool odds ratios (ORs) with 95% confidence intervals (CIs), assessing heterogeneity via I² and Cochran’s Q statistics. Publication bias was evaluated using the trim-and-fill method.

RESULTS: Sixteen studies analyzing 42 HLA markers were included. Pooled ORs indicated increased PD risk with insignificant heterogeneity for HLA-B*07, HLA-C*07:02, HLA-DQA1*01:02, HLA-DQA1*05:05, HLA-DRB1*03:01, and HLA-DRB1*15:01, with protective effects for HLA-DQB1*03:02 and HLA-DQB1*04:01. The analysis for HLA genotypes showed substantial heterogeneity across the studies. The publication bias effect was limited using trim-and-fill method, affecting all the homogenous analyses. HLA-DR expression correlated with motor-cognitive function, and HLA-DQB1*06:02 was linked to daytime sleepiness.

CONCLUSION: Specific HLA alleles influence PD susceptibility and clinical presentation, highlighting the immune system’s role in PD pathogenesis. Future research may explore the influence of HLA haplotypes on PD to ascertain whether there is a direct impact or if the associations are merely a consequence of linkage disequilibrium.

PMID:41032234 | DOI:10.1007/s10072-025-08525-9

Eur Arch Paediatr Dent. 2025 Oct 1. doi: 10.1007/s40368-025-01115-5. Online ahead of print.

ABSTRACT

PURPOSE: This study aimed to evaluate the effectiveness of the “Marzhan Tis” mobile application in improving oral hygiene practices among children with autism spectrum disorder (ASD) and to examine its usability and correlation with learning success.

METHODS: A prospective, non-randomized cohort study was conducted with 90 children aged 3-18 years diagnosed with Level 1 ASD from rehabilitation centers in Almaty, Kazakhstan. Participants were divided into an intervention group (IG), which used the app for 1 month, and a control group (CG), which received standard oral hygiene instructions. Oral hygiene was assessed using the Simplified Oral Hygiene Index (OHI-S), approximal plaque index (API), and papillary-marginal-alveolar index (PMA). Adherence was measured using the modified Oral Hygiene Assessment Scale (OHAS-10), and a structured 15-item caregiver questionnaire evaluated behavioral changes and app usability. Statistical analysis included the Shapiro-Wilk test for normality, Mann-Whitney U and Wilcoxon signed-rank tests for between and within-group comparisons, Chi-square tests for categorical variables, and Pearson correlation for usability-learning associations.

RESULTS: Significant improvements were observed in the IG for all oral hygiene indices (OHI-S reduction: 28-52%; API and PMA improvement > 50%, p < 0.05). Oral hygiene adherence increased by 18.8% (p = 0.001). Independence in brushing improved in 85% of IG children (χ² = 28.7, p = 0.001). A strong correlation was found between app usability and learning outcomes (r = 0.65, p = 0.01).

CONCLUSION: The “Marzhan Tis” mobile app effectively improved oral hygiene skills and independence in children with ASD Level 1. Its usability and gamified features support its integration into pediatric oral health interventions.

PMID:41032232 | DOI:10.1007/s40368-025-01115-5