Category: Nevin Manimala

EBioMedicine. 2026 Jul 16;130:106371. doi: 10.1016/j.ebiom.2026.106371. Online ahead of print.

ABSTRACT

BACKGROUND: Benefits from clinical guidelines often only exceed harms after 10 years (payoff time). Based on population norms, guidelines are often discontinued at 75 years of age, but survival likely differs for those with complex chronic disease. We compare estimates based on age alone versus the physiologically based Veterans Ageing Cohort Study-Charlson Comorbidity Index (VACS-CCI) among all patients in care, and among patients with diabetes or HIV.

METHODS: Estimates for patients in care within the US Veterans Health Administration (VHA) with a clinic visit in 2007-17 (followed thru 2021) were compared using C-statistics, Brier Scores, and calibration curves. “Physiological age” was defined as the chronological age at which median VACS-CCI matched US population survival estimates. Among those with 10-year follow-up, we compared percent correctly classified using age ≥75 years vs. VACS-CCI score of ≥42.

FINDINGS: Among 6.6 million (51.4% ≥ 65 years; 25.2% with diabetes; 0.5% with HIV) VACS-CCI improved discrimination over age (Overall C-statistic: 0.81 vs. 0.74; Brier Score 0.239 vs. 0.262). Among 65-year-old males-females, “physiological age” exceeded chronological age by 4.6-3.1 years overall; 8.6-7.8 years for diabetes; and 13.5-11.6 years for HIV. Compared to age ≥75 years, VACS-CCI improved correct classification of survival for 1 in 13.3 overall; 1 in 7.8 with diabetes; and 1 in 6.4 with HIV.

INTERPRETATION: Compared to chronological age alone, VACS-CCI offers an improved method to identify those likely to reach minimum payoff time, especially for those with complex chronic diseases. Use of clinical data to assess “physiological age” could improve healthcare value.

FUNDING: This work was supported by National Institutes of Health NIAAA: P01 AA029545, U24 AA020794 and the Emory Center for AIDS Research (P30AI050409).

PMID:42462282 | DOI:10.1016/j.ebiom.2026.106371

JMIR Form Res. 2026 Jul 16;10:e86214. doi: 10.2196/86214.

ABSTRACT

BACKGROUND: Completion of homework, defined as therapeutic activities assigned between sessions to reinforce skills and promote behavior change, is strongly linked to therapy outcomes. Yet, homework compliance remains low, potentially due to outdated delivery methods such as paper or email. Mobile health technologies may improve engagement by digitizing therapy tasks and tracking progress. Yosa is a mobile health app designed to facilitate homework delivery and enhance engagement between sessions for patients in therapy.

OBJECTIVE: The primary aim of this study was to evaluate the perceived acceptability of Yosa among licensed therapists and individuals currently receiving therapy. A secondary aim was to examine whether key Technology Acceptance Model (TAM) constructs predicted attitudes toward and intention to use Yosa. Qualitative feedback was also collected to inform iterative development and future deployment.

METHODS: Two cross-sectional surveys were conducted: study 1 with licensed therapists (N=45) and study 2 with current therapy patients (N=96). Participants viewed video demonstrations of Yosa, learned about Yosa’s features, and rated the app on TAM constructs, including perceived usefulness, perceived ease of use, perceived risk, attitude toward, and intention to use Yosa, using 0-100 scales. For most constructs, higher scores reflected more favorable evaluations, whereas lower perceived risk scores reflected more favorable evaluations. Descriptive statistics and 95% CIs were generated for each construct in both samples, with scores interpreted relative to the neutral midpoint (50). Multiple regression analyses were conducted to examine predictors of attitude and intention to use. Qualitative feedback from the surveys was analyzed thematically.

RESULTS: Therapists and patients reported generally favorable perceptions of Yosa across TAM domains. Among therapists and patients, ratings of the perceived usefulness of the homework feature, therapy journal, and overall app; perceived ease of use; attitudes toward Yosa; and intention to use were all above the midpoint. Perceived risk scores were mild to moderate in patients and moderate in therapists, respectively. Regression analyses indicated that perceived usefulness was a positive predictor of both attitude toward and intention to use Yosa across therapists and patients, while perceived risk was negatively associated with these outcomes in several models. Qualitative themes included requests for additional features, usability enhancements, and data privacy concerns.

CONCLUSIONS: Therapists and patients reported generally favorable perceptions of Yosa after reviewing descriptions and video demonstrations of the platform, particularly in terms of usefulness and ease of use, supporting favorable perceptions of its potential acceptability as a digital tool for between-session therapy support. Qualitative feedback informed refinements aimed at reducing perceived risks and enhancing the intention to use.

PMID:42462276 | DOI:10.2196/86214

JMIR Res Protoc. 2026 Jul 16;15:e93097. doi: 10.2196/93097.

ABSTRACT

BACKGROUND: The cognitive paradigm in medical education is undergoing a transition from traditional knowledge transmission to learner-centered knowledge construction. In China, this shift is aligned with the Outline of the Plan for the Construction of China into an Education Powerhouse (2024-2035), which mandates high-quality, intrinsic development in nursing curricula. While constructivist learning theory (CLT)-based teaching methods (eg, problem-based learning, case-based learning, and situational simulation) have been widely explored across Chinese nursing institutions, the evidentiary base remains geographically fragmented and methodologically heterogeneous. A systematic synthesis is required to inform national, evidence-based educational reforms.

OBJECTIVE: This protocol describes a systematic review and meta-analysis designed to evaluate the effectiveness of CLT-based teaching methods vs traditional lecture-based models on Chinese nursing students’ theoretical knowledge, practical skills, self-directed learning ability, and critical thinking disposition.

METHODS: A comprehensive systematic search will be conducted across 9 electronic databases: PubMed, Web of Science, the Cochrane Library, Embase, CINAHL, China National Knowledge Infrastructure, Wanfang Data, VIP Database (Chinese Scientific and Technological Journal Database), and China Biology Medicine. The search period spans from database inception to September 27, 2025, with a planned update through June 11, 2026, before final synthesis. Randomized controlled trials and quasi-experimental studies involving Chinese nursing students will be included. Two independent reviewers will screen records, perform full-text assessment, extract data using standardized forms, and code composite CLT interventions, digital or technology-enhanced components, and cluster- or class-based designs using prespecified decision rules. Risk of bias will be assessed using the Cochrane Risk of Bias tool 2 (RoB 2) for randomized trials and the Joanna Briggs Institute critical appraisal tools for quasi-experimental studies. Meta-analysis will be performed using RevMan 5.4 and Stata 18.0, with random-effects models and prespecified subgroup and sensitivity analyses.

RESULTS: This protocol was finalized in February 2026. A preliminary systematic search conducted on September 27, 2025, identified 990 records before deduplication. As of February 6, 2026, deduplication had been completed and title and abstract screening had been initiated. Data extraction, risk-of-bias assessment, and statistical synthesis had not yet started at the protocol stage and will be conducted only after completion of the updated search, final study selection, and full-text eligibility assessment. The final search update was scheduled through June 11, 2026, before data synthesis. The results manuscript will be submitted after completion of all prespecified review steps, with the timeline depending on the number and complexity of newly identified studies.

CONCLUSIONS: This review will provide a robust evidentiary foundation for the strategic deployment of constructivist methodologies in Chinese nursing education, specifically addressing the needs of vocational and undergraduate programs in the era of digital transformation.

PMID:42462270 | DOI:10.2196/93097

J Med Internet Res. 2026 Jul 16;28:e80960. doi: 10.2196/80960.

ABSTRACT

BACKGROUND: Malawi was a pioneer among African countries in implementing a coordinated, government-led effort to streamline COVID-19 support using digital health tools. In response to the pandemic, a COVID-19 WhatsApp chatbot was developed to support the public with information, symptom reporting, and service navigation during the pandemic.

OBJECTIVE: This study describes the national deployment, functionality, and use patterns of the WhatsApp chatbot during the COVID-19 pandemic in Malawi.

METHODS: A retrospective descriptive analysis of chatbot interaction data from May 2020 to May 2023 was conducted. User engagement with key chatbot functions was summarized using descriptive statistics, and time-series analysis was used to compare trends in reported COVID-19 cases with access patterns to the chatbot, the emergency operation call center, and Chipatala cha pa Foni (a national hotline initiative).

RESULTS: The chatbot was accessed 347,117 times, with 70.8% (n=245,895) of validated WhatsApp accesses focused on COVID-19 statistics. Chatbot use patterns showed temporal alignment with COVID-19 case trends, particularly during the first and second pandemic waves and increases observed after lockdown events. Throughout the pandemic, chatbot downtime occurred in 38% (407/1070) of days, with the most prolonged period coinciding with the national vaccine rollout in 2021, during which vaccine-related functionalities were introduced. Following this expansion, the chatbot recorded 198 COVID-19 vaccine-related rumors and 644 accesses to vaccine frequently asked questions. Compared with call-based services, the chatbot recorded higher overall interactions, whereas symptoms were more frequently reported through call center platforms.

CONCLUSIONS: This study provides a descriptive account of the development and use of a national COVID-19 WhatsApp chatbot in Malawi. The findings highlight patterns of information-seeking behavior, variation in feature use, and the influence of system availability on engagement. These insights may inform the design, implementation, and sustainability of digital health communication tools in similar settings.

PMID:42462223 | DOI:10.2196/80960

JMIR Med Inform. 2026 Jul 16;14:e82230. doi: 10.2196/82230.

ABSTRACT

BACKGROUND: Effective risk stratification in sepsis remains a critical clinical challenge. Serum lactate is a cornerstone biomarker of metabolic dysfunction, yet its predictive limitations-particularly in patients without severe hyperlactatemia-are well recognized. The lactate-to-albumin ratio (LAR), a composite mixed-unit index integrating markers of acute metabolic dysfunction and systemic inflammation, has emerged as a promising predictor; however, its incremental discriminative advantage over lactate had not been formally tested in a large multicenter cohort using paired statistical methodology.

OBJECTIVE: This study aims to determine whether LAR provides statistically significantly higher prediction of 28-day mortality than lactate alone in adult intensive care unit (ICU) patients with sepsis, using threshold effect analysis, restricted cubic splines, DeLong test, and 9 interpretable machine learning models.

METHODS: We conducted a retrospective analysis of 3637 adult patients with sepsis from the multicenter eICU Collaborative Research Database (eICU-CRD; 208 hospitals, United States, 2014-2015). The primary outcome was 28-day all-cause in-hospital mortality among patients surviving the initial 48-hour ICU admission period. We used multivariable logistic regression (LR), Cox proportional-hazards regression, threshold effect analysis, restricted cubic spline modeling, DeLong test for area under the receiver operating characteristic curve (AUC) comparison, and machine learning models evaluated with Shapley additive explanations (SHAP) for interpretability. The cohort was divided 70/30 (stratified) into training and held-out test sets; the Synthetic Minority Oversampling Technique was applied exclusively within the training partition to prevent data leakage.

RESULTS: LAR consistently demonstrated stronger and more stable associations with mortality than lactate across all subgroups. DeLong test confirmed statistically significantly higher AUC for LAR: 28-day hospital mortality (AUC_LAR=0.646, 95% CI 0.623-0.670 vs AUC_lactate=0.617, 95% CI 0.593-0.641; Z=6.37; P<.001; ΔAUC=0.029) and 28-day ICU mortality (AUC_LAR=0.642 vs AUC_lactate=0.621; Z=3.71; P<.001). A nominally significant Acute Physiology and Chronic Health Evaluation IV (APACHE IV) × LAR interaction (hospital mortality, P for interaction=.02) indicated stronger LAR prognostic effects in lower-severity patients (APACHE IV≤70), representing within-biomarker effect modification requiring prospective validation. Among 9 machine learning models for ICU mortality, LR, random forest (RF), and gradient-boosting decision tree (GBDT) achieved the 3 highest AUCs (0.727, 0.726, and 0.725); Light Gradient Boosting Machine (LightGBM) demonstrated the best calibration (Brier score 0.096, the only model below the null Brier of 0.101 at the natural prevalence of 11.4%); GBDT achieved the highest precision-recall AUC (0.293). SHAP identified LAR among the top 10 predictive features in 3 of 4 models for hospital mortality (RF rank 4, LR rank 7, and LightGBM rank 8) and 1 of 4 for ICU mortality (RF rank 4).

CONCLUSIONS: LAR demonstrates statistically significantly higher discrimination than lactate alone for 28-day sepsis mortality prediction. LAR may offer greater prognostic utility in patients without severe hyperlactatemia, a population in whom early risk stratification may be particularly relevant.

PMID:42462220 | DOI:10.2196/82230

Acute Med. 2025;24(4):168-174. doi: 10.52964/AMJA.1024.

ABSTRACT

BACKGROUND: Angioedema is the development of non-pitting edema of the skin and mucosal tissues of the oropharynx, upper respiratory tract, and the gastrointestinal tract. Given the potential for airway compromise, the treatment strategy usually involves a broad approach by addressing multiple underlying possible pathologies simultaneously without knowing the exact mechanism. This is a common and often necessary approach when managing a critically ill patient with incomplete information. Although the current research on TXA use in angioedema centers on ACE-I induced mechanisms, the authors frequently see it used in undifferentiated angioedema.

METHODS: This is a retrospective comparative study evaluating the effect of intravenous TXA administration to treat acute angioedema when compared to usual treatment. Hospital admissions, repeat ED visits specifically related to angioedema within 30 days, 30-day all-cause mortality, and need for an advanced airway were assessed as outcomes.

RESULTS: After applying inclusion and exclusion criteria, 562 ED encounters were identified for chart review. Matched ED encounters comparing TXA use and no TXA use were well balanced. No statistically significant difference was identified when using TXA or not for angioedema when examining the outcome variables.

CONCLUSION: No significant differences were seen between the groups when evaluating ED revisits related to angioedema, hospital admission, the need for an advanced airway, and 30-day all-cause mortality. Prospective analysis of TXA in angioedema is needed to clarify its role in acute treatment.

PMID:42462217 | DOI:10.52964/AMJA.1024

Acute Med. 2025;24(4):164-167. doi: 10.52964/AMJA.1023.

ABSTRACT

BACKGROUND: Deep vein thrombosis (DVT) is commonly managed in ambulatory care. Guidelines recommend reassessment at three months to review anticoagulation duration, but no structured follow-up pathway exists within our Trust.

AIM: To evaluate anticoagulation duration, follow-up practices, and outcomes in patients with DVT diagnosed in ambulatory care.

METHODS: Retrospective, observational service evaluation across two ambulatory care units in Manchester, UK. Patients with confirmed lower limb DVT were identified between January 2023 and June 2023. Data were collected from electronic patient records including complication rates over a 2-year period.

RESULTS: Of 307 patients assessed for suspected DVT, 90 had confirmed DVT. Most cases were unprovoked (77.8%). At discharge, 39% were prescribed 3 months’ anticoagulation, 31% 6 months, 11% lifelong, 6% received a duration range of 3-6 months, and 13% had no specified duration. Discrepancies between recommendation at discharge and primary care prescribing were seen in 53%, with nearly half receiving longer treatment. 20% had secondary care follow-up. Recurrent DVT occurred in nine patients, none of whom had received follow-up; no recurrences were seen in the followed-up group, although this difference was not statistically significant (Fisher’s exact test, p = 0.195). Bleeding events were seen in 4.4% of cases and were minor.

CONCLUSIONS: There is substantial variability in anticoagulation management following DVT in ambulatory care. Although recurrence was not observed in the followed-up group, the study was not powered to detect differences, and this finding should be interpreted cautiously. Further work is needed to establish if a follow-up DVT clinic will improve patient outcomes.

PMID:42462216 | DOI:10.52964/AMJA.1023

JMIR Cancer. 2026 Jul 16;12:e87232. doi: 10.2196/87232.

ABSTRACT

BACKGROUND: Lung cancer remains a major contributor to cancer mortality in sub-Saharan Africa (SSA), where late diagnosis, driven by low awareness, sociocultural barriers, and health system constraints, limits effective treatment. Despite the growing burden, evidence on patients’ quality of life (QoL) and symptom experience in SSA is limited.

OBJECTIVE: This study aimed to describe the common symptoms and QoL of patients with lung cancer treated at 2 hospitals in SSA, and to investigate the association of demographics, clinical characteristics, and symptom burden with QoL.

METHODS: This was a cross-sectional study that consecutively recruited patients with lung cancer from 2 teaching hospitals in SSA: Bugando Medical Centre (BMC) in Tanzania and the University of the Witwatersrand Centre of Respiratory Excellence (WITS-CORE) in South Africa. Data collected included demographics, clinical information, and performance status using the Eastern Cooperative Oncological Group Performance Scale (ECOG-PS). Health-related QoL was assessed using the 30-item European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30). The study followed all ethical procedures, and data were analyzed using both descriptive and inferential statistics in Stata 18. A P value of <.05 was considered statistically significant.

RESULTS: A total of 174 patients with lung cancer were enrolled across the 2 sites. The score on the EORTC QLQ-C30 global health status/QoL subscale was low, with a median of 41.67 (IQR 33.33-41.67), and it varied by site. Patients from WITS-CORE demonstrated higher social functioning scores, while those from BMC reported greater financial difficulties. A low global health status/QoL score was independently associated with the BMC site (adjusted odds ratio [aOR] 3.5, 95% CI 1.3-9.3) and poor performance status (ECOG-PS 3-4; aOR 3.4, 95% CI 1.2-6.6). Furthermore, symptoms such as nausea and vomiting, pain, dyspnea, insomnia, appetite loss, diarrhea, and financial struggles were all associated with a low global health status/QoL score.

CONCLUSIONS: QoL among patients with lung cancer in SSA is poor. Low QoL is strongly associated with the Multinational Lung Cancer Control Program study site, poor performance status, and a range of symptoms and financial difficulties. Addressing these factors may help to improve patient outcomes and well-being in SSA.

PMID:42462209 | DOI:10.2196/87232

JCO Clin Cancer Inform. 2026 Jul-Sep;10(3):e2500213. doi: 10.1200/CCI-25-00213. Epub 2026 Jul 16.

ABSTRACT

PURPOSE: Enzalutamide or abiraterone, combined with androgen-deprivation therapy, is standard of care for metastatic castration-sensitive prostate cancer (mCSPC). However, no trials have compared these drugs. This study compared clinical outcomes in patients with mCSPC treated with enzalutamide or abiraterone.

METHODS: This retrospective cohort study included patients with mCSPC initiating enzalutamide or abiraterone between January 1, 2020, and December 31, 2023, within the nationwide US Veterans Affairs health care system. Inverse probability of treatment weighting was used to balance baseline characteristics. Restricted mean survival time (RMST) differences in overall survival (OS), time to treatment switch or death (TTS), and prostate cancer survival (PCS) were evaluated.

RESULTS: The study included 5,135 patients with mCSPC treated with enzalutamide (1,803) or abiraterone (3,332). The median age was 74.33 years; 58.0% were non-Hispanic White, 28.2% non-Hispanic Black, and 5.6% Hispanic. After weighting, baseline characteristics were well balanced. The median follow-up was 18.74 months for abiraterone and 24.76 months for enzalutamide. Outcomes were similar overall: for OS, the 3-year RMST difference was 0.72 months (95% CI, -0.06 to 1.50); for TTS, the 3-year RMST difference was 0.53 months (95% CI, -0.45 to 1.51), and for PCS, the 1-year RMST difference was -0.12 months (95% CI, -0.35 to 0.11). In subgroup analysis, enzalutamide was associated with improved OS among patients age 75 years and older (3-year RMST difference: 1.65 months, 95% CI, 0.41 to 2.89), but not among younger patients (3-year RMST difference: 0.13 months, 95% CI, -0.86 to 1.11).

CONCLUSION: In this nationwide cohort study, enzalutamide and abiraterone yielded comparable OS, TTS, and PCS outcomes overall, although a small but statistically significant OS benefit was observed for enzalutamide among older patients (≥75 years). These real-world findings from the largest integrated US health care system may provide guidance for selecting mCSPC treatments, although residual confounding cannot be fully excluded.

PMID:42462188 | DOI:10.1200/CCI-25-00213

Neurology. 2026 Aug 11;107(3):e218282. doi: 10.1212/WNL.0000000000218282. Epub 2026 Jul 16.

ABSTRACT

BACKGROUND AND OBJECTIVES: Endovascular thrombectomy (EVT) improves outcome in acute ischemic stroke (AIS) due to large vessel occlusion, yet the optimal anesthetic strategy remains controversial. Previous meta-analyses using frequentist methods reported no significant differences between general anesthesia (GA) and non-GA techniques; however, a recently published trial reported a high posterior probability of functional benefit with GA. We aimed to update the existing systematic review and to re-examine the cumulative randomized evidence using Bayesian statistical methods.

METHODS: We conducted a systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines. PubMed/MEDLINE, Embase, and Cochrane Central Register of Controlled Trials were searched from inception to January 3, 2026, for randomized controlled trials (RCTs) comparing GA with non-GA strategies during EVT in adults with AIS. Primary outcomes were functional independence (modified Rankin Scale [mRS] 0-2) at 90 days, successful reperfusion (thrombolysis in cerebral ischemia 2b-3), and 90-day mortality. Bayesian random-effects meta-analyses with weakly informative priors were performed. Results are reported as odds ratio (OR) or mean difference (MD) with 95% credible intervals (CrIs). A posterior probability of superiority exceeding 80% was considered substantial evidence of benefit. Meta-regression and sensitivity analyses were conducted.

RESULTS: Ten RCTs (n = 1,601; mean age 70.0 years; 46.6% female) were included. For functional independence, GA was associated with a 94.2% posterior probability of superiority (OR 1.24, 95% CrI 0.94-1.66). GA was associated with higher successful reperfusion rates (OR 1.73, 95% CrI 1.23-2.43; P (superiority) > 99%). No substantial differences were observed for 90-day mortality (OR 0.92, 95% CrI 0.67-1.27; P [superiority] 69%), excellent functional outcome (mRS 0-1; OR 1.06, 95% CrI 0.80-1.41; P [superiority] 67%), or symptomatic intracranial hemorrhage (OR 0.93, 95% CrI 0.56-1.52; P [superiority] 62%). GA was associated with increased intraoperative hypotension (OR 4.28, 95% CrI 2.35-7.86; P [superiority] 0.01%) and increased pneumonia risk (OR 1.60, 95% CrI 0.95-2.81; P [superiority] 3%).

DISCUSSION: This meta-analysis using a Bayesian approach provides evidence that GA during EVT for AIS is associated with improved functional outcomes, challenging previous conclusions of equivalence. These findings should be interpreted considering open-label designs and heterogeneous non-GA comparators. They suggest that GA may be preferred but confirmatory evidence is needed.

PMID:42462185 | DOI:10.1212/WNL.0000000000218282