Category: Nevin Manimala

JMIR Aging. 2025 Apr 11;8:e69504. doi: 10.2196/69504.

ABSTRACT

BACKGROUND: Polypharmacy, the concurrent use of multiple medications, is prevalent among older adults and associated with increased risks for adverse drug events including falls. Deprescribing, the systematic process of discontinuing potentially inappropriate medications, aims to mitigate these risks. However, the practical application of deprescribing criteria in emergency settings remains limited due to time constraints and criteria complexity.

OBJECTIVE: This study aims to evaluate the performance of a large language model (LLM)-based pipeline in identifying deprescribing opportunities for older emergency department (ED) patients with polypharmacy, using 3 different sets of criteria: Beers, Screening Tool of Older People’s Prescriptions, and Geriatric Emergency Medication Safety Recommendations. The study further evaluates LLM confidence calibration and its ability to improve recommendation performance.

METHODS: We conducted a retrospective cohort study of older adults presenting to an ED in a large academic medical center in the Northeast United States from January 2022 to March 2022. A random sample of 100 patients (712 total oral medications) was selected for detailed analysis. The LLM pipeline consisted of two steps: (1) filtering high-yield deprescribing criteria based on patients’ medication lists, and (2) applying these criteria using both structured and unstructured patient data to recommend deprescribing. Model performance was assessed by comparing model recommendations to those of trained medical students, with discrepancies adjudicated by board-certified ED physicians. Selective prediction, a method that allows a model to abstain from low-confidence predictions to improve overall reliability, was applied to assess the model’s confidence and decision-making thresholds.

RESULTS: The LLM was significantly more effective in identifying deprescribing criteria (positive predictive value: 0.83; negative predictive value: 0.93; McNemar test for paired proportions: χ²₁=5.985; P=.02) relative to medical students, but showed limitations in making specific deprescribing recommendations (positive predictive value=0.47; negative predictive value=0.93). Adjudication revealed that while the model excelled at identifying when there was a deprescribing criterion related to one of the patient’s medications, it often struggled with determining whether that criterion applied to the specific case due to complex inclusion and exclusion criteria (54.5% of errors) and ambiguous clinical contexts (eg, missing information; 39.3% of errors). Selective prediction only marginally improved LLM performance due to poorly calibrated confidence estimates.

CONCLUSIONS: This study highlights the potential of LLMs to support deprescribing decisions in the ED by effectively filtering relevant criteria. However, challenges remain in applying these criteria to complex clinical scenarios, as the LLM demonstrated poor performance on more intricate decision-making tasks, with its reported confidence often failing to align with its actual success in these cases. The findings underscore the need for clearer deprescribing guidelines, improved LLM calibration for real-world use, and better integration of human-artificial intelligence workflows to balance artificial intelligence recommendations with clinician judgment.

PMID:40215480 | DOI:10.2196/69504

J Med Internet Res. 2025 Apr 11;27:e65452. doi: 10.2196/65452.

ABSTRACT

BACKGROUND: Transgender and gender diverse (TGD) individuals are disproportionately impacted by suicidal thoughts and behaviors (STBs), and intersecting demographic and psychosocial factors may contribute to STB disparities.

OBJECTIVE: We aimed to identify intersecting factors associated with increased risk for suicidal ideation, intent, plan, and attempts in the US transgender population health survey (N=274), and determine age of onset for each outcome using conditional inference trees (CITs), which iteratively partitions subgroups of greater homogeneity with respect to a specific outcome.

METHODS: In separate analyses, we restricted variables to those typically available within electronic medical records (EMRs) and then included variables not typically within EMRs. We also compared the results of the CIT analyses with logistic regressions and Cox proportional hazards models.

RESULTS: In restricted analyses, younger adults endorsed more frequent ideation and planning. Adults aged ≤26 years who identified as Black or with another race not listed had the highest risk for ideation, followed by White, Latine, or multiracial adults aged ≤39 years who identified as sexual minority individuals. Adults aged ≤39 years who identified as sexual minority individuals had the highest risk for suicide planning. Increased risk for suicidal intent was observed among those who identified as multiracial, whereas no variables were associated with previous suicide attempts. In EMR-specific analyses, age of onset for ideation and attempts were associated with gender identity, such that transgender women were older compared to transgender men and nonbinary adults when they first experienced ideation; for attempts, transgender women and nonbinary adults were older than transgender men. In expanded analyses, including additional psychosocial variables, psychiatric distress was associated with increased risk for ideation, intent, and planning. High distress combined with high health care stereotype threat was linked to increased risk for intent and for suicide planning. Only high everyday discrimination was associated with increased risk for lifetime attempts. Ages of onset were associated with gender identity for ideation, the intersection of psychiatric distress and drug use for suicide planning, and gender identity alone for suicide attempts. No factors were associated with age of onset for suicide intent in the expanded variable set. The results of the CIT analysis and the traditional regressions were comparable for ordinal outcomes, but CITs substantially outperformed the regressions for the age of onset outcomes.

CONCLUSIONS: In this preliminary test of the CIT approach to identify subgroups of TGD adults with increased STB risk, the risk was primarily influenced by age, racial identity, and sexual minority identity, as well as psychiatric distress, health care stereotype threat, and discrimination. Identifying intersecting factors linked to STBs is vital for early risk detection among TGD individuals. This approach should be tested on a larger scale using EMR data to facilitate service provision to TGD individuals at increased risk for STBs.

PMID:40215479 | DOI:10.2196/65452

JMIR Public Health Surveill. 2025 Apr 11;11:e64663. doi: 10.2196/64663.

ABSTRACT

BACKGROUND: Molecular HIV surveillance (MHS) can be used to help identify and respond to emerging clusters of rapidly spreading HIV transmissions, a practice known as cluster detection and response (CDR). In the United States, MHS relies on HIV gene sequences obtained from routine clinical antiretroviral resistance testing (ARVRT). By law, ARVRT results are reported to public health agencies for MHS and individuals are not asked for their specific consent to do so. This practice has raised ethical concerns, including the lack of consent for, and transparency surrounding, public health uses of these clinical data. Such concerns have spurred debate and could have a chilling effect on the willingness of people living with HIV to agree to ARVRT when recommended clinically and jeopardize the utility of MHS-informed HIV prevention efforts. In response to the lack of routine disclosure of use of ARVRT results for MHS, in 2022, the Presidential Advisory Council on HIV/AIDS (PACHA) issued a resolution calling on the US Centers for Disease Control to “require that providers explain MHS/CDR and the laboratory test results that are collected and used in these surveillance activities to their patients.”

OBJECTIVE: This study aimed to examine the effect of clinician disclosure of the public health uses of ARVRT results for MHS versus clinician nondisclosure on patient willingness to undergo recommended ARVRT.

METHODS: We conducted a randomized survey experiment examining the effect of clinician disclosure of the public health uses of ARVRT results for MHS versus clinician nondisclosure (the current standard of care) and subsequent discovery of such uses through a “trusted media source” on patient willingness to undergo recommended ARVRT. Study participants were respondents to 1 of 2 national web-based surveys conducted annually in the United States: the American Men’s Internet Survey (AMIS) and the Transgender Women’s Internet Survey and Testing (TWIST).

RESULTS: Overall, 4348 AMIS participants (n=2151 disclosure; n=2197 nondisclosure) and 3314 TWIST participants (n=1670 disclosure; n=1644 nondisclosure) completed survey items regarding the randomly assigned vignettes. The majority were willing to undergo ARVRT regardless of which vignette they saw (1670/2151, 82.7% [AMIS] and 1326/1670, 80.8% [TWIST] in the disclosure group; and 1399/2197, 68% [AMIS] and 1101/1674, 68.45% [TWIST] in the nondisclosure group) after later learning about public health uses of ARVRT results.

CONCLUSIONS: The majority of respondents expressed willingness to undergo ARVRT even with disclosure of public health uses of these data, but willingness markedly decreased when learning about these uses after the fact, highlighting the importance of transparency in MHS programs. Accordingly, in line with the ethical principle of respect for autonomy and the likelihood that the potential public health benefits of MHS programs will not be compromised, consideration should be given to encouraging clinicians to disclose public health uses of ARVRT at the time ARVRT is recommended.

PMID:40215474 | DOI:10.2196/64663

J Am Acad Orthop Surg Glob Res Rev. 2025 Apr 8;9(4). doi: 10.5435/JAAOSGlobal-D-24-00146. eCollection 2025 Apr 1.

ABSTRACT

INTRODUCTION: With the advent of new classification systems and surgical options, clarification is needed regarding the most effective surgical management for refractory patellar tendinopathy (PT). The objective of this systematic review is to investigate outcomes of surgical management of refractory PT.

METHODS: PubMed was searched from January 1, 2000, through July 12, 2021, using the Medical Subject Headings function and the following Boolean operators: “Patellar Ligament/surgery”[Mesh] NOT “Anterior Cruciate Ligament”[Mesh]. Original research articles that discussed surgical management of PT were included, and outcomes were recorded.

RESULTS: Fifteen studies (2 studies level 1 and 13 studies level 4) were included comprising 485 patients with an average age of 29.5 years and 523 patellar tendons treated. The seven studies reporting both preoperative and postoperative Victorian Institute of Sports Assessment scores demonstrated increases of 39.60, whereas the seven studies reporting visual analog scores demonstrated decreases of 6.11. Average return-to-play rate was 87.08%. Study designs and in surgical techniques were heterogenous, which precluded the ability to perform a meta-analysis.

DISCUSSION: Surgical treatment of refractory PT leads to notable improvement in patient-reported outcomes and high return-to-play rates. However, there is a paucity of high-quality research investigating newer surgical options and classification systems for PT.

PMID:40215473 | DOI:10.5435/JAAOSGlobal-D-24-00146

JMIR Med Inform. 2025 Apr 11;13:e70752. doi: 10.2196/70752.

ABSTRACT

BACKGROUND: Improving processes regarding the management of electronic health record (EHR) requests for chronic antihypertensive medication renewals may represent an opportunity to enhance blood pressure (BP) management at the individual and population level.

OBJECTIVE: This study aimed to evaluate the effectiveness of the eRx HTN Chart Check, an integrated clinical decision support tool available at the point of antihypertensive medication refill request, in facilitating enhanced provider management of chronic hypertension.

METHODS: The study was conducted at two Mayo Clinic sites-Northwest Wisconsin Family Medicine and Rochester Community Internal Medicine practices-with control groups in comparable Mayo Clinic practices. The intervention integrated structured clinical data, including recent BP readings, laboratory results, and visit dates, into the electronic prescription renewal interface to facilitate prescriber decision-making regarding hypertension management. A difference-in-differences (DID) design compared pre- and postintervention hypertension control rates between the intervention and control groups. Data were collected from the Epic EHR system and analyzed using linear regression models.

RESULTS: The baseline BP control rates were slightly higher in intervention clinics. Postimplementation, no significant improvement in population-level hypertension control was observed (DID estimate: 0.07%, 95% CI -4.0% to 4.1%; P=.97). Of the 19,968 refill requests processed, 46% met all monitoring criteria. However, clinician approval rates remained high (90%), indicating minimal impact on prescribing behavior.

CONCLUSIONS: Despite successful implementation, the tool did not significantly improve hypertension control, possibly due to competing quality initiatives and high in-basket volumes. Future iterations should focus on enhanced integration with other decision support tools and strategies to improve clinician engagement and patient outcomes. Further research is needed to optimize chronic disease management through EHR-integrated decision support systems.

PMID:40215469 | DOI:10.2196/70752

J Clin Oncol. 2025 Apr 11:JCO2401739. doi: 10.1200/JCO-24-01739. Online ahead of print.

ABSTRACT

PURPOSE: Prognostic staging after neoadjuvant chemotherapy (NACT) is not included in American Joint Commission on Cancer (AJCC) staging. This study addressed this deficiency by including responses to therapy with standardized staging variables in a validated prognostic staging system for patients treated with NACT.

METHODS: The National Cancer Database was queried to identify 140,605 patients treated with NACT between 2010 and 2018. Three response categories (no response, partial response, and complete response [pCR]) were created on the basis of comparison of clinical and post-NACT pathologic staging. Univariate and multivariate analyses of clinical stage, estrogen receptor, progesterone receptor, human epidermal growth factor receptor 2 (HER2), and grade were analyzed for each category. Predictive models for each response category were validated using the bootstrap technique. Calibration plots compared predicted and observed 3-year survival probabilities in the training and validation data sets.

RESULTS: Each validated model demonstrated statistically significant survival differences in the postneoadjuvant prognostic stage assignment. Of all patients with a pCR, 94.2% were assigned to postneoadjuvant ypStage I compared with 35.5% of patients with no response. Advancing clinical stage had a progressive but small impact on overall survival (OS) with pCR (high-grade, triple-negative breast cancer [TNBC]: cStage I, 97% v cStage IIIB/IIIC, 91%; grade 2 luminal A: 97% v 91%) but was associated with a profound decrease in OS with no response for TNBC or HER2+ disease (high-grade TNBC 89% v 50%) and less profound for grade 2 luminal A disease with no response (97% v 81%).

CONCLUSION: We present a novel, validated prognostic staging system that predicts OS according to the response to NACT. These data will provide AJCC stage assignments for a growing proportion of patients treated with NACT.

PMID:40215445 | DOI:10.1200/JCO-24-01739

JCO Glob Oncol. 2025 Apr;11:e2400615. doi: 10.1200/GO-24-00615. Epub 2025 Apr 11.

ABSTRACT

PURPOSE: Oncology has experienced substantial growth in clinical trial activity over the past two decades, but a comprehensive evaluation of radiation oncology research is lacking. This study analyzed trends in radiation therapy trials using data from ClinicalTrials.gov.

MATERIALS AND METHODS: A comprehensive analysis was conducted on 4,253 radiation oncology trials registered in the database. Key outcomes examined included trends in trial activity over time, the geographic distribution of trials, and the phases of clinical trials conducted.

RESULTS: Clinical trial activity in radiation oncology has increased significantly, with 4,253 trials registered by February 2024. Digestive, CNS, and head and neck cancers accounted for 49.7% of studies. Research on oligometastasis emerged in the past decade (2.2%), while hematology trials declined (9.7%). Phase II trials dominated (51.3%), with most originating in North America (58.2%). Europe (21.2%) and Asia (25.2%) have shown increasing contributions, reflecting a global shift. Only 6% of trials received industry funding, highlighting the financial challenges in the field.

CONCLUSION: These findings underscore the dynamic nature of radiation oncology research and the need to address regional disparities, advance novel technologies and drug-radiotherapy combinations through phase I and III trials, and increase industry investment.

PMID:40215439 | DOI:10.1200/GO-24-00615

JCO Glob Oncol. 2025 Apr;11:e2400255. doi: 10.1200/GO-24-00255. Epub 2025 Apr 11.

ABSTRACT

PURPOSE: In 2012, Kenya announced its commitment to prioritizing cervical cancer (CC) services with the National Cervical Cancer Prevention Program. However, gaps in implementation remain, causing suboptimal uptake. The goal of this study is to provide a situational analysis of 19 government health facilities in Kenya to assess facilities’ capacity to provide CC screening and treatment.

METHODS: We conducted a retrospective data review at 19 health facilities in Siaya and Busia counties of Kenya from September 2021 to September 2022 to assess availability and uptake of CC services. Key variables included hospital volume, positivity, and numbers of women screened, treated, and referred. Notes were taken to document challenges with service provision and data collection. The retrospective review informed site matching for a proposed cluster-randomized trial.

RESULTS: There were a total of 16,757 CC screenings or rescreenings documented across the 19 study sites during the study period. Across the 19 facilities, 10.8% of the women enrolled in care at the hospital were screened during the data collection period. The overall positivity was 3.8% but ranged from 0.7% to 16.7%. Of the 19 facilities offering CC screening, five lacked the required equipment to provide same-day treatment, and complex referral pathways were noted for women needing to seek care elsewhere. Challenges with documentation were noted at all stages of CC services.

CONCLUSION: Gaps noted were low screening rates, opportunities to improve the efficiency of CC services, structural limitations in implementing the screen-and-treat approach, and poor documentation of CC services and outcomes. Urgent action is needed to ensure that all facilities offering CC screening are equipped with the personnel, supplies, and equipment necessary to conduct guideline-adherent same-day cryotherapy or thermal ablation treatment and improve documentation at the facility level to track CC services across the cascade of care.

PMID:40215437 | DOI:10.1200/GO-24-00255

J Clin Oncol. 2025 Apr 11:JCO2402026. doi: 10.1200/JCO-24-02026. Online ahead of print.

ABSTRACT

In the phase III CodeBreaK 300 study, sotorasib 960 mg-panitumumab significantly prolonged progression-free survival (PFS) versus investigator’s choice (trifluridine/tipiracil or regorafenib) in patients with KRAS G12C-mutated chemorefractory metastatic colorectal cancer (mCRC). One hundred sixty patients were randomly assigned 1:1:1 to receive sotorasib 960 mg-panitumumab (n = 53), sotorasib 240 mg-panitumumab (n = 53), or investigator’s choice (n = 54; crossover permitted after primary analysis). Overall survival (OS) analysis, a key secondary end point, although not adequately powered, was prespecified at 50% maturity (after approximately 80 deaths). In this study, we report the OS, updated overall response rates (ORRs), and data for safety. After a median follow-up of 13.6 months, 24, 28, and 30 deaths occurred in the sotorasib 960 mg-panitumumab, sotorasib 240 mg-panitumumab, and investigator’s choice arms, respectively; updated objective response rates (ORRs; 95% CI) were 30.2% (95% CI, 18.3 to 44.3), 7.5% (95% CI, 2.1 to 18.2), and 1.9% (95% CI, 0.0 to 9.9), respectively. Compared with investigator’s choice, the hazard ratios (HRs [95% CI]) for OS were 0.70 (95% CI, 0.41 to 1.18; two-sided P = .20) with sotorasib 960 mg-panitumumab and 0.83 (95% CI, 0.49 to 1.39; two-sided P = .50) with sotorasib 240 mg-panitumumab. No new safety signals were observed. Although not statistically significant, the observed OS HR and ORR along with prior PFS and safety findings support sotorasib 960 mg-panitumumab as a standard of care in patients with chemorefractory KRAS G12C mCRC.

PMID:40215429 | DOI:10.1200/JCO-24-02026

J Int Med Res. 2025 Apr;53(4):3000605251328617. doi: 10.1177/03000605251328617. Epub 2025 Apr 11.

ABSTRACT

IntroductionClavicular fractures, particularly comminuted fractures, are common injuries that can affect shoulder function and upper limb mobility. The management of these fractures, especially using surgical approaches and fixation methods, remains a key area of clinical focus. Preserving the periosteum during surgery may improve fracture healing and reduce complications. This study explored the clinical efficacy of a periosteum-preserving surgical technique combined with a Nice knot-assisted locking plate for treating comminuted clavicular fractures.MethodsA total of 85 patients with comminuted clavicular fractures were included in this retrospective study. According to the Allman classification, 56 (65.9%) cases were type IC, 19 (22.4%) were type II, 9 (10.9%) were type III, and 1 (1.1%) involved comminuted fractures across the entire clavicle. All patients underwent surgical treatment using a periosteum-preserving approach combined with a Nice knot-assisted locking plate. Fracture healing time, upper limb function (measured via Constant-Murley score and disabilities of the arm, shoulder, and hand questionnaire), and postoperative complications were assessed 6 and 12 months postoperatively.ResultsThe median healing time was 13 weeks, with no cases of nonunion reported. At 6 months postoperatively, the Constant-Murley and disabilities of the arm, shoulder, and hand scores were excellent. Although a statistically significant difference (P < 0.05) was observed in these scores between 6 and 12 months, all patients reported satisfactory recovery of shoulder function and upper limb mobility. No significant differences (P > 0.05) in fracture healing time or upper limb function recovery were observed across different types of clavicular fractures. Six (7.1%) patients experienced temporary numbness in the subclavian region, which gradually resolved by the final follow-up.ConclusionThe periosteum-preserving approach with Nice knot-assisted locking plate fixation proved to be an effective and reliable treatment for comminuted clavicular fractures. The technique was associated with favorable healing times, excellent functional outcomes, and low complication rates. Preservation of the periosteum and soft tissue during surgery may considerably reduce intraoperative trauma and improve postsurgical recovery. Further studies with larger sample sizes and longer follow-up periods are needed to confirm the long-term benefits of this approach.

PMID:40215412 | DOI:10.1177/03000605251328617