Category: Nevin Manimala

Prehosp Emerg Care. 2026 Jul 7:1-11. doi: 10.1080/10903127.2026.2697436. Online ahead of print.

ABSTRACT

OBJECTIVES: Sudden cardiac death is a leading cause of death globally. Recent guidelines recommend considering extracorporeal cardiopulmonary resuscitation (ECPR) for refractory cardiac arrest, but evidence regarding favourable outcomes remains scarce.

METHODS: This nationwide retrospective observational study analyses ECPR for out-of-hospital cardiac arrest (OHCA) in Germany. The Federal Statistical Office of Germany provided data for all refractory OHCA patients in German hospitals between 2018 and 2023, including identification of those who received ECPR. All patients aged 18 years and older were included. The primary endpoint was hospital mortality. Secondary endpoints were centre caseload and location.

RESULTS: Between 2018 and 2023 27,056 patients were admitted with OHCA refractory to conventional CPR and 785 (2.9%) received ECPR. Survival without ECPR was 11.3% and 11.8% with ECPR, with no significant difference between the groups. ECPR utilization increased from 1.8% (n = 62) in 2018 to 4.1% (n = 168) in 2023, but survival rates remained unchanged. Among hospitals treating patients with OHCA, 11.6% (n = 102) provided ECPR. The median number of annual cases per ECPR centre was three. Urban centres had higher prior VA ECMO experience and ECPR caseload. Survival was higher for urban centres, though not statistically significant.

CONCLUSIONS: Between 2018 and 2023, ECPR was used for 2.9% of refractory OHCA cases admitted to hospitals in Germany. ECPR utilization increased while survival remained unchanged at approximately 12%. The widespread provision of ECPR by institutions with low case volume, within the specific regulatory and organisational context of the German health care system, underscores the need for national quality standards and registries to improve consistency of ECPR care.

PMID:42413030 | DOI:10.1080/10903127.2026.2697436

J Cardiovasc Pharmacol. 2026 Jul 7. doi: 10.1097/FJC.0000000000001832. Online ahead of print.

ABSTRACT

Anthracyclines remain a cornerstone of cancer therapy but are associated with a spectrum of cardiovascular toxicity, ranging from subclinical myocardial injury to overt heart failure (HF). Despite strong biological rationale, the role of universal pharmacologic prophylaxis remains uncertain. In this context, the recent meta-analysis by Pizzi et al. provides a timely synthesis of randomized evidence evaluating angiotensin-converting enzyme inhibitors (ACEi) for the prevention of anthracycline-related cardiotoxicity. The analysis demonstrates a statistically significant attenuation of left ventricular ejection fraction decline with ACEi prophylaxis, although the absolute effect size is modest and accompanied by substantial heterogeneity. Importantly, the magnitude of benefit appears to be context-dependent, with more consistent effects observed in higher-risk settings, such as combined anthracycline and trastuzumab exposure or in patients with early markers of myocardial injury. Contemporary data suggest that declining event rates and improved supportive care may limit the ability of prophylaxis trials to detect clinically meaningful differences in low-risk populations. Furthermore, the absence of significant effects on clinical endpoints underscores the limitations of current surrogate markers and trial design. Emerging evidence supports a more nuanced, risk-adapted approach, integrating early detection strategies such as global longitudinal strain and biomarker-guided intervention. Within this framework, ACEi prophylaxis may be most appropriately targeted to patients with higher baseline risk or early evidence of myocardial injury, rather than applied universally. Future studies should prioritize risk enrichment, standardized imaging protocols, and clinically meaningful outcomes to better define the role of cardioprotective strategies in cardio-oncology.

PMID:42413029 | DOI:10.1097/FJC.0000000000001832

G3 (Bethesda). 2026 Jul 7:jkag165. doi: 10.1093/g3journal/jkag165. Online ahead of print.

ABSTRACT

Polyploidy has repeatedly shaped grass evolution, yet direct observations of how polyploid-derived chromosomes behave when returned to diploidy remain rare. Interspecific crosses between diploid Sorghum bicolor and tetraploid hybrids derived from S. halepense generate mixed-ploidy progeny, providing an opportunity to examine chromosome transmission during the early stages of diploidization. Using genome-wide SNP markers, we characterized chromosomal inheritance patterns in two diploid and two tetraploid families derived from these crosses. Genotype-dosage profiles alone distinguished diploids from tetraploids with complete accuracy, reflecting strong ploidy-dependent differences in dosage-class distributions. Although diploid progeny retained much of the halepense-derived genomic background, several genomic intervals exhibited extended, non-random runs of S. bicolor homozygosity that remained polymorphic in corresponding tetraploid populations. These patterns, together with recurrent segregation distortion across independent families, suggest that the transition from tetraploidy to diploidy can expose allelic combinations that differ in transmission or viability. Analyses of flowering time further indicated that diploid and tetraploid derivatives possess distinct genomic architectures, with major association peaks occurring in different chromosomal regions across ploidy levels. Collectively, these results indicate that early diploidization involves non-random retention and loss of parental haplotypes shaped by both selective and structural constraints. The diploid extractions characterized here provide a rare empirical system for investigating the early stages of diploidization and a practical framework for studying and eventually mobilizing polyploid-derived variation into sorghum germplasm development. However, broader integration into elite breeding programs will require additional evaluation of cross-fertility, meiotic behavior, and chromosomal stability across diverse breeding backgrounds.

PMID:42413025 | DOI:10.1093/g3journal/jkag165

Menopause. 2026 Jul 7. doi: 10.1097/GME.0000000000002849. Online ahead of print.

ABSTRACT

OBJECTIVES: To evaluate longitudinal changes in climacteric symptom burden and health-related quality of life between 6 and 12 months after breast cancer surgery and to assess whether symptom trajectories differ according to age or clinical and treatment-related factors using the minimal clinically important difference (MCID).

METHODS: Prospective longitudinal cohort study including women surgically treated for breast cancer at Hospital General Universitario Dr. Balmis (Alicante, Spain) between April 2023 and April 2024. Of the 196 women assessed at 6 months, 181 completed the 12-month follow-up and were included in the final longitudinal analysis. Climacteric symptoms were assessed at 6 and 12 months post-surgery using the 16-item Cervantes Scale. Within-participant changes were analyzed using the Wilcoxon signed-rank test, estimating the Hodges-Lehmann shift and effect size. Subgroup comparisons were performed using nonparametric tests with Bonferroni correction. Age-stratified analyses were conducted across five predefined age groups. Clinical relevance was evaluated against the MCID.

RESULTS: The 16-item Cervantes Scale total score showed a statistically significant change between 6 and 12 months; however, the magnitude of this change was small and remained below the MCID, indicating overall symptom stability. Age-stratified analyses identified statistically significant changes in women aged 40-49, 50-59, and 60-69 years, but these remained below the MCID thresholds, and did not reflect clinically meaningful improvement. No clinical, lifestyle, or treatment-related variables were associated with differential symptom trajectories.

CONCLUSIONS: Between 6 and 12 months after surgery, climacteric symptom burden in breast cancer survivors showed minimal change. Although statistically significant differences were observed, these remained below the MCID and are therefore unlikely to represent clinically meaningful changes. These findings support the need for early, proactive, and multidisciplinary management strategies to optimize health-related quality of life during survivorship in this population.

PMID:42413023 | DOI:10.1097/GME.0000000000002849

JMIR Res Protoc. 2026 Jul 7;15:e91051. doi: 10.2196/91051.

ABSTRACT

BACKGROUND: High mortality and prevalence rates are hallmarks of chronic heart failure (CHF). Patients frequently have a much lower quality of life as a result of diminished exercise tolerance. Chinese guidelines have recommended Yiqi Fumai lyophilized injection (YQFM) for the treatment of heart failure, although there is currently inadequate evidence to support its effectiveness in increasing exercise tolerance in these patients.

OBJECTIVE: The purpose of this cohort study is to examine the relationship between the improvement of exercise tolerance in patients with CHF and the addition of YQFM to guideline-directed medical therapy.

METHODS: In total, 216 hospitalized patients with CHF with New York Heart Association (NYHA) functional classes II-IV were to be enrolled in the prospective, observational cohort trial design. The participants were divided into a YQFM group (exposed group: n=144) and a non-YQFM group (nonexposed group: n=72) at a 2:1 ratio based on real clinical medication and patient preference. Standard guideline-directed medical therapy was administered to both groups; however, the YQFM group also got a 10-day YQFM exposure. The change in metabolic equivalents measured by the Veterans Specific Activity Questionnaire was the main outcome. The 6-minute walk distance, Kansas City Cardiomyopathy Questionnaire score, NYHA functional class, N-terminal pro-B-type natriuretic peptide levels, and echocardiographic parameters were among the secondary objectives. Traditional Chinese medicine syndrome scores and the frequency of hard clinical occurrences were the exploratory objectives. A linear mixed-effects model was used to examine repeated measurement data, and propensity score weighting was used to account for baseline confounding variables.

RESULTS: The first patient was registered in June 2024, and all 216 patients had been recruited and followed up with by December 2025. Data cleaning and statistical analysis began in January 2026, with final results scheduled to be published in the autumn of 2026.

CONCLUSIONS: This study, using a prospective cohort design, intends to offer high-quality, real-world evidence for the use of YQFM in cardiac rehabilitation for heart failure. This will aid in the optimization of preventative and treatment strategies for CHF that combine traditional Chinese and Western medicine, giving an objective basis for enhancing patients’ long-term quality of life.

PMID:42413004 | DOI:10.2196/91051

Braz J Psychiatry. 2026 Jul 7. doi: 10.47626/1516-4446-2026-4868. Online ahead of print.

ABSTRACT

BACKGROUND: Brazil’s Unified Health System (SUS) mental inpatient care relies on government funding, especially in structurally unequal regions. Despite funding concerns, general hospitals manage serious mental disorders strategically.

OBJECTIVE: Determine if federal transfers cover the true cost of psychiatric hospitalizations in a Northern Brazilian general hospital.

METHODS: This cross-sectional cost analysis examined all 2023 psychiatric admissions in the Dr. Emílio Vasques Psychiatric Unit, General Hospital of Palmas, Tocantins. While the institution has 22 inpatient beds, only 11 are registered and eligible for federal funding by the Ministry of Health. Direct and indirect costs were evaluated using microcosting and absorption costing. Official national databases provided federal transfer statistics.

RESULTS: 421 hospitalizations. Annual costs was BRL 13.984.390,24 (USD 3,107,642.28). Spending was 44.6% direct and 55.4% indirect. The average hospitalization cost BRL 33.217,08 (USD 7,381.57). Federal transfers covered 12% of direct hospitalization expenditures, half the unit’s operational capacity.

CONCLUSION: Federal funding for mental inpatient care is insufficient, transferring the financial burden to state governments and compromising service viability.

PMID:42412980 | DOI:10.47626/1516-4446-2026-4868

NEJM Catal Innov Care Deliv. 2026 Feb;7(2):CAT250237. doi: 10.1056/CAT.25.0237. Epub 2026 Jan 21.

ABSTRACT

Vitamin D testing is frequently overused across U.S. health systems, with much of it occurring outside the bounds of evidence-based clinical indications. Despite clear guidance from the Endocrine Society and the U.S. Centers for Medicare and Medicaid Services, routine screening in low-risk populations remains common and costly. Within Oregon, vitamin D testing has been identified as one of the top 15 low-value services, representing a substantial opportunity for cost savings and practice alignment. In an effort to reduce the volume of low-value vitamin D testing across a three-hospital academic health system, a multidisciplinary working group designed and implemented an electronic health record best practice advisory to fire at the point of order entry when a vitamin D test was attempted without an approved indication. The initiative involved implementing a targeted clinical decision support intervention, aligned with evidence-based diagnostic coding curated using the U.S. Centers for Medicare and Medicaid Services coverage criteria and reinforced by coordinated communication and measurement infrastructure. The proportion of indicated vitamin D tests increased from 45% (939 of 2060) in the final month pre intervention to more than 88% (1194 of 1354) at 90 days post intervention, and remained above 90% (1381 of 1531) at 1 year post go-live. Improvements were consistent across payer types, age groups, and locations of care, with the largest gains seen in outpatient and Medicaid populations. In absolute terms, the number of vitamin D tests decreased by 25.3% (to 16,530 from 22,129) when comparing the 12 months pre intervention with the 12 months post intervention. Along with this decrease was an estimated cost savings of nearly US$112,000. The intervention significantly improved ordering appropriateness while maintaining access to necessary testing. It required no additional staffing or investment in new infrastructure. Provider feedback highlighted the value of peer engagement, transparency in metric definitions, and responsiveness to edge cases. Data revealed attempts to bypass the best practice advisory using unspecified diagnosis codes. A simple, well-targeted clinical decision support tool, paired with strategic communication and disciplined measurement, can lead to meaningful reductions in low-value vitamin D testing. Sustained improvement depends on transparent metrics, engaged leadership, and a willingness to challenge entrenched ordering habits while remaining attentive to clinical nuance.

PMID:42412971 | DOI:10.1056/CAT.25.0237

NEJM Catal Innov Care Deliv. 2026 Feb;7(2):CAT250205. doi: 10.1056/CAT.25.0205. Epub 2026 Jan 21.

ABSTRACT

Emergency department (ED) crowding, constrained inpatient capacity, and long waits for outpatient cardiology delay care for patients with urgent cardiac symptoms. In 2016, the Beth Israel Deaconess Medical Center opened a non-ED-based, cardiologist-staffed Cardiac Direct Access Clinic with examination rooms, an infusion room, and six overnight observation beds to provide rapid specialty evaluation and short-stay care. Using administrative data and contribution-margin analyses, the authors assessed operational, clinical, and financial outcomes and summarized implementation strategies. Of 11,121 total patients seen in the clinic, 4239 patients – those most likely to have otherwise been sent to the ED – were admitted on the same day of referral. Of those patients, 59% were discharged home, 39% were managed in the Cardiac Direct Access Clinic’s overnight unit, and 7% ultimately were admitted to inpatient floors. Among 1467 patients discharged from the overnight unit, the 30-day return rate to the ED was 6.4%. Overall patient experience scores were higher for the clinic than for the ED – 84.7 versus 56.9. Annual labor and supply costs for the clinic totaled approximately US$1.8 million. The contribution margin derived from the clinic’s operations (US$245,000), admissions originating from the clinic (US$303,000), and inpatient capacity created (US$1.34 million) produced an estimated US$2.4 million annual contribution margin, underscoring financial sustainability. Key enablers included centralized prior-authorization teams, state approval to operate as an alternative care space for inpatient-level services, and codified diversion pathways for the ED and urgent care.

PMID:42412968 | DOI:10.1056/CAT.25.0205

J Med Internet Res. 2026 Jul 7;28:e86087. doi: 10.2196/86087.

ABSTRACT

BACKGROUND: Limited data availability and privacy constraints hinder the development of robust survival prediction models for personalized treatment. Synthetic data offers a promising solution, preserving the statistical properties of real clinical data.

OBJECTIVE: This study aimed to quantitatively assess the feasibility of using synthetic data for survival prediction by evaluating model transfer performance to real-world hospital data, with a focus on model transfer strategies.

METHODS: We developed and validated colorectal cancer survival prediction models using the National Cancer Data Center (NCDC) synthetic data (30,683 patients from 3 Korean institutions) for pretraining and real hospital data (2170 patients from Hwasun Jeonnam University Hospital) for external validation. We evaluated 3 model transfer strategies-domain adaptation, zero-shot, and ensemble-using extreme gradient boosting (XGBoost) and light gradient boosting machine (LightGBM). In total, 48 model configurations were tested, defined by the combination of algorithms (LightGBM and XGBoost), sampling technique (no-sampling, random undersampling [RUS], and synthetic minority oversampling technique combined with edited nearest neighbors [SMOTEENN]), model type (baseline, domain adaptation, zero-shot, and ensemble), and optimization objective (area under the precision-recall curve [AUPRC] and F1). The outcome was 7-year overall survival, evaluated using the AUPRC and Brier scores. Performance was compared against a hospital-only baseline using absolute values and deltas (ΔAUPRC and ΔBrier). Differences and corresponding 95% CIs were estimated on the held-out test set using 2000 bootstrap samples.

RESULTS: Zero-shot application reduced the AUPRC in most settings, and any marginal improvements observed in the remaining settings were not statistically significant. In contrast, the domain adaptation model improved AUPRC in 8/12 combinations, with 4 statistically significant gains; the best setting (XGBoost+RUS+F1 optimization) achieved AUPRC=0.5391 (Δ+0.1474; P<.001). The soft ensemble increased AUPRC in 7/12 combinations, with 3 statistically significant gains; the best setting (XGBoost+RUS+AUPRC optimization) achieved AUPRC=0.5060 (Δ+0.1258, P=.002). For calibration, Brier scores improved in most domain adaptation and ensemble combinations, with a substantial proportion reaching statistical significance.

CONCLUSIONS: When domain adaptation using local hospital data was applied, the model pretrained on synthetic data exhibited similar performance to the hospital-only baseline across various settings. This study demonstrates the methodological utility of a model transfer approach using NCDC synthetic data in a setting with limited data sharing. At the same time, it clarifies that while synthetic data can serve as a complement to local clinical data, it is not a substitute for real-world clinical models.

PMID:42412950 | DOI:10.2196/86087

JMIR Med Inform. 2026 Jul 7;14:e85015. doi: 10.2196/85015.

ABSTRACT

BACKGROUND: The increasing documentation burden on physicians is a significant contributor to burnout and decreases in care quality. Artificial intelligence (AI) has been proposed as a solution to reduce documentation burden in clinical care, but there are very limited data on its use in the inpatient and intensive care unit (ICU) environments.

OBJECTIVE: This pilot study aimed to explore the feasibility of using AI-assisted ambient scribes to capture interprofessional ICU rounds and synthesize a singular document to improve documentation efficiency and clinician satisfaction during ICU rounds. In this paper, we showcase our findings from customizing prompts for large language models (LLMs) to generate and evaluate daily progress notes from transcripts of simulated ICU cases.

METHODS: This project is divided into 2 phases. In the first phase, a randomly selected transcript of an audio recording of a simulated ICU rounds case was used to iteratively evaluate and improve the prompts for the LLMs. Multiple models (n=5) were used in phase 1, and the best-performing model (M1, based on the highest accuracy) was selected for the next phase. In the subsequent phase, 5 cases were selected and evaluated using the refined prompt and 2 models: M1 from phase 1 and M6, a technological upgrade of M1. Accuracy and error percentages were used as primary metrics. Additionally, error severity and usability were assessed using the Harm scale (adapted for potential harm risk) from the Agency for Healthcare Research and Quality and the 9-item Physician Documentation Quality Instrument, respectively.

RESULTS: Iterative improvements to the prompt increased accuracy and reduced errors during phase 1. In phase 2, M1 and M6 achieved accuracies of 69% and 80%, respectively (P=.04). Overall, errors of omission were most common (mean 15.5%, SEM 2.7%), followed by partial errors (mean 7.2%, SEM 0.92%) and then errors of commission (mean 2.6%, SEM 0.7%). The error severity of both models was low (µ=0.61 vs 0.53; P=.10), with most errors categorized as having potential for no harm to low harm. Both models performed well on the 9-item Physician Documentation Quality Instrument assessment, with the M6 model outperforming the M1 (35.8 vs 38.3; P=.06).

CONCLUSIONS: Our findings demonstrate the feasibility of integrating AI-assisted scribes for ICU documentation. Both prompt improvements and technological advancements in LLMs are noted to be helpful. This study lays the groundwork for future research into AI applications in ICU settings, paving the way for broader improvements in health care documentation.

PMID:42412948 | DOI:10.2196/85015