Nevin Manimala

Environ Health. 2026 May 23. doi: 10.1186/s12940-026-01309-4. Online ahead of print.

ABSTRACT

BACKGROUND: Taiwan is one of the fastest-warming regions globally. As climate change intensifies, understanding how vulnerability influences health outcomes critical. This study aimed to identify regional vulnerability factors for temperature-related respiratory mortality and effective region-specific adaptation policies.

METHODS: A two-stage time-series study was conducted using daily respiratory mortality counts aggregated by county and day. This study employed a distributed lag non-linear model to estimate the temperature-attributable mortality burden from respiratory diseases across all counties and cities in Taiwan. A two-stage meta-analysis was conducted to estimate temperature-mortality associations and quantify cold- and heat-related mortality burdens by county. Meta-regression was used to identify regional vulnerability factors modifying temperature-related mortality risk, and geographically weighted regression (GWR) was applied to characterize the spatial heterogeneity of these effects across counties.

RESULTS: Cold exposure was linked to a higher burden of respiratory disease mortality (attributable fraction [AF]: 2.03%, 95% CI: 1.10-2.95) than heat exposure (AF: 1.02%, 95% CI: 0.65-1.40). For cold-related AFs, higher proportions of Indigenous populations (3.27, 0.79-5.75), low-income populations (2.11, 0.67-3.55), greater population density (2.21, 0.46-3.96), and children (0.98, 0.35-1.61) were significantly associated with increased risk, suggesting vulnerability factors. GWR further showed that hospital bed availability had statistically significant protective effects against cold-related AF in 10 of 19 counties (β = – 5.24 to – 6.78), most pronounced in remote mountainous counties (Hualien, Taitung, Kaohsiung).

CONCLUSION: Higher proportions of Indigenous populations, low-income population, and children amplify cold-related respiratory mortality. Hospital bed availability confers the strongest protection against cold-related mortality in remote, mountainous counties. Climate adaptation policies for cold-related respiratory health should therefore be tailored to local vulnerability profiles, prioritizing healthcare expansion in geographically remote counties rather than applying uniform investment across all regions.

PMID:42177497 | DOI:10.1186/s12940-026-01309-4

Fluids Barriers CNS. 2026 May 23. doi: 10.1186/s12987-026-00819-0. Online ahead of print.

ABSTRACT

BACKGROUND: Endoscopic third ventriculostomy with choroid plexus cauterization (ETV/CPC) offers an alternative to shunt placement for infant hydrocephalus, avoiding shunt-related complications when successful. However, approximately 40% of procedures fail, with 30% ultimately requiring shunt placement. Current risk stratification relies primarily on age and prior interventions, limiting ability to optimize treatment selection. Therefore, this study aimed to determine whether preoperative cerebrospinal fluid volume (CSFV) measurements independently predict shunt-dependence following ETV/CPC in infant hydrocephalus.

METHODS: This retrospective cohort study was conducted from 2008 to 2024, with follow-up through 2024 and statistical analysis performed in January 2025. Infants who underwent ETV/CPC as the primary treatment for hydrocephalus and had magnetic resonance imaging within two weeks before surgery were included. The primary outcome was shunt-dependence, defined as progressive ventriculomegaly requiring shunt placement after ETV/CPC. Imaging measures included traditional frontal-occipital horn ratio (FOHR) and novel volumetric assessments: CSFV and CSFV/intracranial volume (ICV) ratio estimated using deep learning-based segmentation methods and the corresponding z-scores using age- and sex- adjusted normative curves. Cox proportional hazards regression identified independent predictors of shunt-dependence.

RESULTS: A total of 188 infants (median age at surgery 60 days, 42.5% female) were included. Sixty-six (35.8%) patients became shunt-dependent over a median follow-up of 3.8 years as of January 2025. In multivariable analysis adjusting for age and prior temporary CSF diversion, both CSFV z-score (HR 1.10, 95%CI 1.02-1.20, p = 0.02) and CSFV/ICV ratio z-score (HR 1.07, 95%CI 1.01-1.13, p = 0.02) independently predicted shunt-dependence, while FOHR did not achieve statistical significance in adjusted models. Younger infants with higher CSFV z-scores demonstrated elevated failure rates.

CONCLUSIONS: Preoperative CSF volume measurements provide superior risk stratification compared to traditional linear assessments for predicting shunt-dependence in infant hydrocephalus. These findings support integration of volumetric brain imaging analysis into clinical decision-making to optimize treatment selection and improve outcomes through more precise identification of candidates most likely to benefit from ETV/CPC versus primary shunt placement.

PMID:42177495 | DOI:10.1186/s12987-026-00819-0

BMC Med Educ. 2026 May 23. doi: 10.1186/s12909-026-09525-9. Online ahead of print.

ABSTRACT

INTRODUCTION: Anatomy teaching in preclinical medical education has become increasingly compressed, making it more difficult for students to integrate foundational anatomical knowledge with clinical reasoning. Upper limb nerve lesions are particularly challenging to learn because they require spatial understanding and application of structure-function relationships, yet students often struggle to translate two-dimensional instructional materials into clinical reasoning. This study presents a preliminary evaluation of a medical student-developed, three-dimensional (3D) interactive simulation designed to model upper limb nerve lesions and their associated motor, sensory, and reflex deficits.

METHODS: First-year medical students who had completed the standard anatomy curriculum participated in a single-session pilot study with room-level random allocation comparing a traditional PowerPoint-based review (2D Review Group) with an interactive simulation (3D Simulation Group). Both groups completed identical worksheets and a five-item multiple-choice pre- and post-test assessing clinical application of anatomy knowledge. Post-session surveys evaluated perceived clarity, clinical relevance, and educational value. Knowledge gains were compared using Mann-Whitney U tests with effect size calculations, and open-ended survey responses were analyzed using Reflexive Thematic Analysis (RTA) following Braun and Clarke.

RESULTS: A total of 35 students participated, with 33 included in the knowledge gain analysis. Both instructional groups showed improvement on the post-test. Although differences in change scores were not statistically significant (U = 165.00, p = .274), the 3D Simulation Group showed a larger median gain and reached similar post-test scores to the 2D Review Group despite lower baseline performance. Survey responses did not differ significantly between groups. Qualitative feedback suggested differing learner priorities across instructional modalities, with participants in the 3D Simulation Group emphasizing visual-spatial support and interactivity, and participants in the 2D Review Group emphasizing structured review and practice questions.

DISCUSSION: Given the single-session design, these findings should be interpreted as exploratory. However, they suggest that interactive 3D simulation may support conceptual understanding and application of anatomical knowledge, particularly for learners with lower baseline knowledge.

CONCLUSION: This study supports the feasibility of a student-led, AI-assisted approach to developing adaptable educational tools within a medical curriculum. Although quantitative differences were modest, qualitative feedback suggests that learners valued the tool’s support for clinical reasoning and spatial understanding. Further longitudinal and multi-session research is needed to evaluate retention, scalability, and educational impact.

PMID:42177489 | DOI:10.1186/s12909-026-09525-9

BMC Nurs. 2026 May 23. doi: 10.1186/s12912-026-04634-8. Online ahead of print.

ABSTRACT

BACKGROUND AND OBJECTIVES: Cancer is one of the leading causes of death globally. Against the backdrop of inadequate life education and a deep-rooted death-avoidant culture in China, oncology nurses faced with multiple challenges in hospice care. The attitude of oncology nurses towards care of the dying is a crucial factor in improving the quality of palliative care. However, few studies have explored the attitude toward care of the dying of oncology nurses and their influencing mechanisms. This study aimed to explore the mediating effect of meaning in life on the fear of death and attitude toward care of the dying among oncology nurses in China.

METHODS: Data were collected from July to August 2024 using Chinese versions of the Frommelt Attitude Toward Care of the Dying Scale, Form B (FATCOD-B-C), the Collett-Lester Fear of Death Scale (CLS), and Purpose in Life Test (CPLT-C). SPSS version 26.0 and AMOS version 24.0 were used for statistical analysis.

FINDINGS: The mean total attitude score towards care of the dying was 95.52 ± 18.18. The fear of death was positively correlated with the meaning in life (r = 0.442, P < 0.01), and positively correlated with the attitude toward care of the dying (r = 0.340, P < 0.01). Meaning in life was positively correlated with attitude towards care of the dying (r = 0.474, P < 0.01). Meaning in life partially mediated the relationship between fear of death and attitudes toward care of the dying. The mediating effect (0.297) accounted for 63.19% of the total impact (0.479).

CONCLUSION: Nurses’ fear of death is positively correlated with their attitude towards care of dying, and the meaning of life plays a partial mediating role in it. This discovery challenges the common view that “fear of death is necessarily detrimental to humanistic care”, highlighting the significant role of existentialist resources in shaping nurses’ professional attitudes. Based on this, intervention measures should focus on strengthening the intermediary resource of life meaning. Medical administrators, educators and policymakers can combine traditional training methods with emerging technologies to help nurses master palliative care knowledge and skills while cultivating and consolidating a sense of life meaning.

PMID:42177484 | DOI:10.1186/s12912-026-04634-8

BMC Cancer. 2026 May 23. doi: 10.1186/s12885-026-16146-4. Online ahead of print.

ABSTRACT

OBJECTIVE: Androgen receptor pathway inhibitors (ARPIs) are cornerstone treatments for advanced prostate cancer; however, their potential to increase fall risk remains a significant clinical concern. This meta-analysis aims to provide a rigorous, drug-specific evaluation of the association between novel ARPIs and the risk of falls.

METHODS: We systematically searched PubMed, Web of Science, Cochrane Library, and ClinicalTrials.gov for Phase 2 or 3 randomized controlled trials (RCTs) comparing ARPIs (enzalutamide, apalutamide, and darolutamide) with control groups (placebo or non-steroidal antiandrogens [NSAA]). The primary outcomes were risk ratios (RRs) for all-grade and grade ≥ 3 falls. To account for multiplicity across correlated outcomes and the limited number of studies, pooled RRs were estimated using random-effects models with the restricted maximum-likelihood (REML) method. All analyses were performed on a logarithmically transformed scale, with 97.5% confidence intervals (CIs). Prediction intervals (PIs) were calculated to assess the dispersion of effects. Subgroup analyses were stratified by specific ARPI agents, control types, and clinical stages.

RESULTS: Eleven RCTs involving 12,239 patients were included. Overall, ARPIs were significantly associated with the increased risk of all-grade falls (RR 2.00, 97.5% CI 1.46-2.73, P < 0.0001, I² = 77.6%; PI 0.67-5.99) and grade ≥ 3 falls (RR 2.15, 97.5% CI 1.32-3.52, P = 0.0008, I² = 0%; PI 1.15-4.02). However, risk profiles varied substantially across individual agents. Enzalutamide was associated with the highest risk increase (RR 2.55 vs. placebo, 97.5% CI 1.62-4.01, I² = 79.2%; RR 2.47 vs. NSAA, 97.5% CI 1.14-5.37, I² = 71.8%), followed by apalutamide (RR 1.65, 97.5% CI 0.77-3.52, I² = 87.2%). In contrast, darolutamide demonstrated a favorable safety profile with no statistically significant increase in the risk of all-grade falls (RR 1.25, 97.5% CI 0.87-1.79, I² = 0%) or severe falls (RR 1.31, 97.5% CI 0.34-5.00).

CONCLUSIONS: Current evidence indicates that the increased risk of falls associated with ARPI therapy varies significantly among individual agents, rather than being a uniform class effect. While enzalutamide and apalutamide are statistically associated with elevated fall risk, darolutamide appears to maintain a more favorable safety profile. However, these drug-specific comparisons remain exploratory due to subgroup imbalances. Clinicians should consider proactive fall-risk assessments and individualized treatment selection, particularly for elderly or frail populations.

PMID:42177476 | DOI:10.1186/s12885-026-16146-4

Cost Eff Resour Alloc. 2026 May 23;24(1):66. doi: 10.1186/s12962-026-00770-9.

ABSTRACT

BACKGROUND: Clinical pathways (CPs) are guidelines to standardize processes, improve quality of care and maximize resources through the implementation of evidence-based care for a medical procedure, thus reducing variation and risk. Our aim was to evaluate the cost of care for robotic colorectal surgery using a CP compared to surgery without a CP.

METHODS: This was a non-interventional micro-costing study with a hospital-level perspective. It was carried out using the three standard steps. First, all resources involved in the implementation of the CP were identified. Second, resource consumption was measured. Third, the resources identified were valued and measured to estimate the average cost per group. This included the costs related to perioperative care and treatment of complications. Finally, a sensitivity analysis was conducted based on the hypothetical capacity utilization of the robotic equipment, costs of CP development and a discount rate of 3% over a period of five years.

RESULTS: The study population comprised 63 patients: 21 in the CP group (robotic colorectal surgery with CP) and 42 in the no-CP group (robotic colorectal surgery without CP). The mean cost per patient in the CP group was €12,663 (range: €8,093 to €26,475), whereas in the no-CP group it was €11,128 (range: €8,357 to €17,268). The main cost drivers in the CP group were materials and disposables (33% of total costs) and staff (20% of total costs). In the no-CP group, they accounted for 38% and 20% of total costs, respectively. The CP group was used for the sensitivity analysis. In year 1, at 100% utilization the mean cost per patient was €12,364, increasing to €17,883 at 20% utilization. In year 5, at 100% utilization the mean cost per patient was €13,986, rising to €20,519 at 20% utilization.

CONCLUSION: The evidence from our study indicates that using a CP for perioperative care of patients undergoing robotic colorectal surgery was not associated with a statistically significant reduction in cost of care.

PMID:42177472 | DOI:10.1186/s12962-026-00770-9

BMC Psychiatry. 2026 May 23. doi: 10.1186/s12888-026-08212-9. Online ahead of print.

ABSTRACT

BACKGROUND: Attention Deficit Hyperactivity Disorder (ADHD) is a common childhood neurodevelopmental disorder characterized by inattention, hyperactivity, and impulsivity beyond developmental expectations. Problematic technology engagement, including increased smartphone use, is frequently observed among adolescents with ADHD. Phubbing, a term combining ‘phone’ and ‘snubbing,’ refers to ignoring others in a social setting by focusing on one’s smartphone rather than engaging in face-to-face interaction and has been linked to impaired interpersonal communication. Cognitive Disengagement Syndrome (CDS), formerly referred to as sluggish cognitive tempo (SCT), is characterized by excessive daydreaming, mental confusion, low initiative, and slowed responding and is associated with social withdrawal. However, no prior studies have investigated ADHD-phubbing or CDS-phubbing relationships in adolescents. This study examined group differences in phubbing and explored associations among phubbing, ADHD symptoms, and CDS severity.

METHODS: In this case-control study, 48 adolescents diagnosed with ADHD and 38 healthy controls aged 12-17 completed; Sociodemographic Data Form, General Phubbing Scale, and Conners-Wells Adolescent Self-Report Scale Short Form. Parents completed Child and Adolescent Behavior Inventory SCT Scale. ADHD was diagnosed via DSM-5 based clinical interviews. Group comparisons and correlation analyses were conducted using appropriate statistical tests.

RESULTS: Phubbing scores were significantly higher in the ADHD group than in controls. Phubbing scores demonstrated significant positive correlations with self-reported ADHD symptom domains, including conduct problems, inattention, hyperactivity, and the ADHD Index. CDS severity did not reach significance within the ADHD group but was significantly associated with phubbing scores in the full sample. Adolescents whose CDS symptoms impaired social functioning reported higher phubbing scores. Daily smartphone use exceeding 3 hours and social media use were also associated with elevated phubbing scores.

CONCLUSION: These findings indicate that phubbing scores is elevated among adolescents with ADHD and is positively associated with ADHD symptom severity. CDS-particularly when accompanied by social impairment-is also associated with higher phubbing scores. The results highlight the potential utility of assessing smartphone and other electronic technology use when evaluating adolescents with ADHD and CDS. However, given the cross-sectional nature of this study, causal or directional inferences cannot be drawn. Future research with larger and untreated samples is warranted.

CLINICAL TRIAL NUMBER: Not applicable.

PMID:42177470 | DOI:10.1186/s12888-026-08212-9

BMC Palliat Care. 2026 May 23;25(1):154. doi: 10.1186/s12904-026-02149-2.

ABSTRACT

BACKGROUND AND OBJECTIVES: Clinical ethics support services (CES) may support palliative care teams in ethical conflicts. However, it is not known to what extent these services are available, used and how their relevance is perceived by the teams. The study focuses on the accessibility and evaluation of ethics consultations in specialized outpatient palliative care teams and inpatient hospices.

METHODS: This study conducted a cross-sectional 21-item anonymous survey among teams of registered specialized outpatient palliative care services (n = 304) and inpatient hospices (n = 260) in Germany concerning availability, utilization and evaluation of clinical ethics support services.

RESULTS: A total of 175 (58%) specialized outpatient palliative care teams and 102 (39%) inpatient hospice teams responded to the questionnaire; of these two-thirds have access to CES. A number of ethical challenges were reported in these settings, many of which are perceived as burdensome. However, satisfaction with existing services is rather moderate and teams report fewer than five consultations per year. Nevertheless, ethics consultation is regarded as being highly useful, with positive effects reported, including enhanced confidence in decision-making processes and reduced burden for team members. Interestingly, team members with formal training in clinical ethics had a significant positive impact on the perception of CES and the frequency of consultations.

CONCLUSION: Although specialized outpatient palliative care and inpatient hospice teams reported facing a number of burdensome ethical challenges, ethics consultations fall short of accessibility to CES. This discrepancy can be resolved by structured training of team members in clinical ethics to increase the level of awareness and utilization of CES in specialized outpatient palliative care and inpatient hospices.

PMID:42177468 | DOI:10.1186/s12904-026-02149-2

Int J Gynaecol Obstet. 2026 May 23. doi: 10.1002/ijgo.71076. Online ahead of print.

ABSTRACT

OBJECTIVE: The aim of the present study was to assess changes in cesarean section (CS) rates over 3 years at a public tertiary care hospital using the Robson Ten Group Classification System (RTGCS). The specific objectives were to compare population distribution across Robson groups, evaluate overall, group-specific, absolute and relative CS rates and assess data quality and completeness.

METHODS: This analytical cross-sectional study was conducted at a public tertiary care hospital in Rawalpindi, Pakistan and spanned over two phases. Phase 1: June 2019 to November 2019 and phase 2: August 2022 to January 2023. For analysis, RTGCS was applied. Robson’s report tables (RRTs) of two phases were generated to calculate and compare CS rates. Statistical analysis included the calculation of P values (considering <0.05 as significant) by chi-square and Fisher exact tests, odds ratios (ORs), relative risks (RRs) and 95% confidence intervals (CIs), using established online tools.

RESULTS: The total number of women included in study during phase 1 were 5437, and in phase 2 were 3762. Overall CS rate increased from 31.06% (phase 1) to 40.09% (phase 2) (P < 0.001). In both phases, Robson group 3 was the largest (33% and 25.2% in phases 1 and 2, respectively) and group 9 was the smallest (<1%). The highest absolute contribution towards CS rate was made by group 5, followed by groups 10 and 2 in both phases. Combined contribution of groups 5, 10, and 2 was 70.5% in phase 1 and 64.9% in phase 2. Group 9 had the highest group-specific CS rate in both phases (93.7% and 100%). In phase 1, it was followed by groups 5 (80.4%), 6 (78.2%) and 7 (72%), while in phase 2 by groups 6 (89.6%), 5 (85.2%), and 8 (72.2%). In CS rate, a statistically significant increase was noted in Robson groups 1, 3, 5, 6, 8, and 10, while a decline was observed in group 4 only.

CONCLUSION: The overall CS rate significantly increased over time. This rise was mainly due to a shift in the obstetric population in high-risk groups; 6, 8, 9, 10, and group 5. Conversely, the reduced CS rates in groups 2 and 4 suggest improved induction practices. The data quality was satisfactory.

PMID:42175756 | DOI:10.1002/ijgo.71076

Risk Anal. 2026 Jun;46(6):e70267. doi: 10.1111/risa.70267.

ABSTRACT

High temperatures are increasingly associated with adverse mental health outcomes, yet the influence of structural modeling assumptions on these estimates remains underexplored. This study examined the short-term association between high temperatures and mental health-related-hospitalizations in 21 major Italian cities from 2005 to 2023, using national hospital discharge data. Exposure-lag-response relationships were modeled through a Distributed Lag Nonlinear Model (DLNM) framework estimated within a Generalized Additive Model (GAM). Analyses focused on June-September and included hospitalizations with a primary diagnosis of mental disorders, considering the code 295-316 of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). A Global Sensitivity Analysis (GSA) assessed how structural decisions, such as the specification of temperature and lag splines, and the inclusion of September, affect risk estimates. A total of 210,310 hospitalizations were recorded. The cumulative exposure-response curve showed a marked nonlinear increase in risk, reaching relative risk values close to two at temperatures exceeding 40 ${}^{\circ }C$ . The GSA revealed that the number and placement of knots in the temperature dimension were the dominant contributors to output variability, with total-order sensitivity indices approaching one across most of the temperature range. Variations in the lag structure contributed minimally, while including or excluding September influenced model fit but only modestly affected risk estimates. Uncertainty quantified through GSA was substantially larger than that quantified by standard confidence intervals, indicating that structural assumptions meaningfully shape inference. Within the DLNM-GAM framework, high summer temperatures were consistently associated with increased psychiatric hospitalizations. Incorporating GSA clarified which modeling choices influence estimates, improving transparency and robustness in evaluating heat-related mental health impacts.

PMID:42175751 | DOI:10.1111/risa.70267