Nevin Manimala

JMIR Form Res. 2026 May 19;10:e78563. doi: 10.2196/78563.

ABSTRACT

BACKGROUND: The COVID-19 pandemic was marked by rapidly evolving and inconsistent public health messaging, contributing to confusion regarding recommended preventive behaviors. Knowledge, attitudes, and practices (KAP) and perceived risk frameworks offer a structured approach to examine how education, personal beliefs, and contextual factors influence health behaviors during public health emergencies. Vulnerable populations, such as patients with multiple sclerosis (MS), experience heightened risk perception compared with the general population, which may further shape behavioral responses.

OBJECTIVE: This study aimed to examine COVID-19-related KAP and perceived risk among patients with MS, health care providers, and laypeople during the first 6 months of the pandemic. The aim of mixed methods was to explore quantitative factors associated with KAP and perceived risk and to qualitatively describe participants’ perceptions and emotional responses to the pandemic.

METHODS: A descriptive, cross-sectional, partially mixed methods explanatory sequential design was used. Participants were recruited using convenience sampling and completed an online demographic questionnaire and a COVID-19 KAP instrument that included perceived risk items. Quantitative data were analyzed using descriptive statistics and inferential analyses to examine group differences and associations between perceived risk and preventive behaviors. Chi-square testing was applied to compare perceived risk across groups, and correlational analyses were used to examine the relationships between perceived risk and behavioral practices. Qualitative comments provided by participants were analyzed using thematic analysis to further contextualize quantitative findings and to explore perceived risk experiences.

RESULTS: A total of 148 participants were included, comprising 43 (29%) individuals with MS, 50 (33.8%) health care providers, and 55 (37.2%) laypeople. Overall, 90% (n=133) of participants demonstrated basic knowledge of COVID-19 transmission and prevention. Attitudes toward public health guidance and self-reported preventive behaviors varied across groups. Lay participants most frequently reported a moderate perceived risk of COVID-19 infection, whereas participants with MS and health care providers more commonly reported high perceived risk (χ²6=12.65, P=.049). Neither immunosuppressive treatment status nor vaccine hesitancy significantly predicted perceived risk. However, higher perceived risk was significantly associated with greater avoidance of crowded and public places. Qualitative analysis yielded 5 interrelated themes describing participants’ perceived risk experiences: uncertainty related to evolving scientific information; anxiety regarding personal and family safety; fear of infection and long-term consequences; vulnerability, particularly among individuals with chronic illness and frontline exposure; and accountability toward protecting others through adherence to preventive measures. These themes provided contextual insight into the emotional and cognitive processes underlying reported attitudes and behaviors.

CONCLUSIONS: Knowledge of COVID-19 is associated with favorable attitudes and engagement in preventive practices across populations. Differences in perceived risk highlight the importance of tailoring risk communication and educational strategies to specific populations. KAP-focused educational interventions that explicitly address uncertainty, emotional responses, and behavioral translation may strengthen preparedness and promote sustained protective behaviors during future public health emergencies.

PMID:42155141 | DOI:10.2196/78563

JMIR Mhealth Uhealth. 2026 May 19;14:e66151. doi: 10.2196/66151.

ABSTRACT

BACKGROUND: Previous research suggests that 14.4% of the general population is affected by tinnitus. For some of those affected, the ear noise is bothersome or associated with severe distress. There are various treatment options such as cognitive behavioral therapy (CBT), sound therapy, or hearing aids. In addition to browser-based online interventions, mobile apps have been introduced as novel treatment approaches. Previous studies have identified several apps aimed at supporting users with tinnitus. Yet, knowledge about the content of tinnitus apps is limited.

OBJECTIVE: This study aimed to provide an overview of apps specifically developed for tinnitus by analyzing general app characteristics, as well as app content, focusing on intervention components and behavior change techniques (BCTs).

METHODS: A systematic search using 7 search terms (eg, tinnitus and ear noise) was conducted in the Google Play Store and the Apple App Store. Apps designed specifically for tinnitus and available in German or English met the inclusion criteria. Two independent trained raters assessed general app characteristics (eg, age group and costs) using the app description section of the German version of the Mobile App Rating Scale. In addition, raters analyzed app content using the BCT taxonomy (v1) and a list of typical intervention components in tinnitus treatment. Differences in ratings were discussed, and a third trained rater was consulted if no consensus was reached.

RESULTS: A total of 1198 apps were identified in the systematic search. Of those, 69 apps were included in the final analysis. Fifty-two apps were available for free, 23 of which offered in-app purchases. Among the 17 paid apps, costs ranged between €0.69 (US $0.81) and €450 (US $527) per 12 months. Fifty-eight of 69 apps provided sounds (eg, white noise and nature sounds). Many apps assessed tinnitus characteristics (n=38) and provided information about tinnitus (n=27). The most frequently used BCTs were “instruction on how to perform the behavior” (n=25; eg, audio instructions for relaxation techniques), “feedback on behavior” (n=11), “behavioral practice/rehearsal” (n=11), “information about health consequences” (n=11), “information about emotional consequences” (n=11), and “prompts/cues” (n=11). The number of BCTs implemented varied widely across apps (0-18 per app).

CONCLUSIONS: Most tinnitus apps offer sound-based interventions (eg, white noise and nature sounds). Notably, CBT elements (eg, cognitive restructuring, attention training, and relaxation training) are implemented less frequently, despite CBT being recommended in tinnitus treatment guidelines. Further research on the efficacy of tinnitus apps is needed. Transparent reporting of intervention techniques may help clarify mechanisms of action and support the replication of effective interventions. Given the large number of readily accessible apps, this study provides an overview relevant to both researchers and health care professionals.

PMID:42155139 | DOI:10.2196/66151

MSMR. 2026 May 15;33(4):10-14.

ABSTRACT

This study utilized de-identified surveillance data to estimate the incidence of head and neck cancer among active component service members (Army, Navy, Air Force, Marine Corps, Coast Guard) from 2010 through 2024. This report updates the June 2021 MSMR analysis of oral and pharyngeal cancers (2007-2019) by expanding the case definition to include all head and neck cancers and extending the surveillance period through 2024. There were 549 cases of head and neck cancer diagnosed in the active component military during the 15-year period of analysis. The Army had the highest 15-year incidence rate (3.3 per 100,000 person-years) compared to the Navy (2.6 per 100,000), Air Force (2.6 per 100,000), Coast Guard (2.0 per 100,000), and Marine Corps (1.3 per 100,000). Service members ages 40 years and older had the highest overall incidence rate (12.3 per 100,000), which was 3.3 times the next highest rate observed among those ages 35-39 years. The 15-year male incidence rate (2.9 per 100,000) was greater than that among females (1.7 per 100,000). The parotid gland was the most common site of diagnosis, comprising 14.8% of cases. This report provides the most current head and neck cancer incidence data for active component service members from 2010 through 2024; it establishes baseline rates for monitoring of future trends and highlights specific high-risk populations (e.g., men, Army personnel, service members ages 40 years and older). Although head and neck cancer is the seventh most prevalent cancer worldwide, its incidence among active component service members is seldom reported. Head and neck cancer is often not diagnosed until it has metastasized. Significant physical limitations (e.g., difficulty chewing, speaking, and swallowing) and psychosocial effects (e.g., anxiety, depression, social isolation), compromising service member readiness, can accompany this type of cancer.

PMID:42155135

MSMR. 2026 May 15;33(4):3-9.

ABSTRACT

Military service members remain a priority population for assessing the prevalence, patterns, and long-term consequences of tobacco and nicotine use. The limitations inherent to documenting use among military service members, however, complicate the design of exposure assessment. This study combined 2 data sources-by aggregating self-reported Periodic Health Assessment (PHA) survey data with International Classification of Diseases, 9th and 10th revisions, Clinical Modification (ICD-9-CM/ICD-10-CM) medical diagnostic codes-to classify nicotine and tobacco use as exposures delineated by recent use or history of any use. The study population included a total of 921,394 U.S. active component service members who completed a PHA in 2023. PHA classification for ‘recent use’ was defined by self-reported use of any tobacco or nicotine product within the past 30 days, whereas ‘history of any use’ included recent users in addition to those who reported cessation of use. The full roster of service members who completed the PHA in 2023 was matched to ambulatory and inpatient medical records within 30 days, before or after, the PHA sample period (December 1, 2022-January 31, 2024) to identify selected ICD-10-CM codes for recent use. Selected diagnostic codes for a ‘history of any use’ were queried for a period of 20 years preceding and 30 days following (January 1, 2004-January 31, 2024) the PHA sample period. Among PHA respondents, 22.0% (n=203,156) self-reported recent nicotine or tobacco use. When aggregating PHA data with recent exposure classified from diagnostic codes, the resulting assessment of recent nicotine or tobacco use increased to 28.7% (n=264,194). Critically, this aggregation identified 61,038 U.S. service members with no evidence of recent use on the PHA but with a concurrent clinical record during the specified matching period. Aggregating data sources for a history of any use only nominally improved the estimate, increasing it from 41.1% (PHA alone) to 43.1%. Agreement between sources was fair for both recent use (κ=0.28) and historical use (κ=0.36). The results of this study indicate that neither self-reported PHA data nor medical diagnostic codes alone provide a complete picture of tobacco and nicotine use among U.S. active component service members. The combination of medical diagnostic codes with self-reported PHA survey responses increases exposure estimates of recent tobacco or nicotine use among U.S. active component service members to 28.7%, in comparison to 22.0% if exclusively assessing recent use from the PHA. The integration of multiple data sources may provide a more comprehensive assessment of recent nicotine and tobacco exposure among service members, directly supporting enhanced public health surveillance.

PMID:42155134

Port J Card Thorac Vasc Surg. 2026 May 10;33(1):19-23. doi: 10.48729/pjctvs.607.

ABSTRACT

INTRODUCTION: The management of chest tubes after pulmonary resection remains non- standardized, and suction levels are often determined by the surgeon’s preference. This retrospective study aimed to compare the clinical outcomes of low suction -2cmH2O-2cmH2​O versus the conventional suction level used in our institution -15cmH2O-15cmH2​O using digital drainage devices after videoassisted thoracic surgery (VATS) lobectomy for suspected or confirmed lung cancer in a thoracic surgery centre.

METHODS: We analysed 120 patients who underwent pleural drainage after VATS lobectomy between January 2023 and September 2024. The primary outcome was drainage duration. Secondary outcomes included hospital stay, prolonged air leak, complications, and readmissions.

RESULTS: No significant differences were observed in drainage duration (2.0 vs. 4.0 days; p=0.125p=0.125) or hospital stay (3.0 vs. 4.0 days; p=0.104p=0.104 ). The incidence of prolonged air leak was similar between groups (20.3% vs. 24.6%; p=0.578p=0.578 ). However, subcutaneous emphysema occurred more frequently in the low suction group (22% vs. 8.2%; p=0.04p=0.04 ), with a higher need for intervention, despite comparable baseline forced expiratory volume in the first second (FEV1) values between suction level groups. Importantly, patients who developed subcutaneous emphysema had significantly lower baseline FEV1 values, regardless of suction level. COPD was identified as a significant predictor of longer drainage duration, longer hospital stay, and higher complication rates.

CONCLUSION: Although suction level did not significantly influence postoperative recovery, the higher incidence of subcutaneous emphysema in the low suction group warrants further investigation. The presence of COPD and impaired baseline lung function should be considered when selecting suction levels after VATS lobectomy.

PMID:42155129 | DOI:10.48729/pjctvs.607

JMIR Hum Factors. 2026 May 19;13:e73369. doi: 10.2196/73369.

ABSTRACT

BACKGROUND: Mental health problems are prevalent among young people aged 16 to 24 years. With the health care system prioritizing severe cases, most young people wait months before accessing professional support. One-to-one helplines offer alternative and accessible mental health services for young people with emotional support, psychoeducation, and signposting. Signposting empowers young people to access long-term support beyond a brief helpline session. However, young people often choose not to access the signposts. Despite its importance, there is a dearth of existing research examining signposting via digital mental health helplines for young people.

OBJECTIVE: Using cross-sectional survey data from The Mix, a UK charity supporting young people aged 25 years or younger, this study conducted a mixed methods analysis of their multichannel (webchat, email, telephone, and web-based contact form) helpline survey between February 2020 and October 2023.

METHODS: The analytic sample included 296 participants who collectively received 872 signposts (approximately 872/4500, 19% of signposts provided during the survey collection period), of which 822 with complete outcome data were included in the statistical models. Multinomial logistic regressions were conducted to examine whether young people’s use and perceived usefulness of the signposts they received differed across modes of delivery and their demographic characteristics (gender, ethnicity, and age). Qualitative thematic analysis of 106 open-ended responses from 97 participants was also examined to illuminate why young people found signposting helpful and how it could be improved.

RESULTS: In the overall model, which included all predictors, webchat users identifying as White, women, and aged 16-19 years were significantly more likely to use and find signposts helpful than to perceive them as unhelpful (odds ratios [OR] 0.28, 95% CI 0.17-0.46; P<.001), not intend to use them (OR 0.13, 95% CI 0.07-0.26; P<.001), or only plan to use them later (OR 0.29, 95% CI 0.18-0.46; P<.001). Thematic analysis of open-ended responses revealed that young people found the choice of signposts relevant and appreciated how signposting was integrated with emotional support. Young people also felt more hopeful after being signposted and gained both clarity and insight into the support available. However, they also noted challenges, such as feeling overwhelmed or encountering outdated signposts.

CONCLUSIONS: Given the increasing reliance on digital mental health services, ensuring that signposting remains accessible, relevant, and tailored to diverse user needs is essential. By optimizing signposting strategies, helplines can empower young people to seek appropriate long-term support, ultimately improving mental health outcomes.

PMID:42155126 | DOI:10.2196/73369

JMIR Form Res. 2026 May 19;10:e84249. doi: 10.2196/84249.

ABSTRACT

BACKGROUND: Despite the notable proliferation of smoking cessation mobile apps, to date, no validated, Spanish-language, culturally tailored mobile intervention exists for Spanish speakers in the United States.

OBJECTIVE: The aim of this study was to conduct formative research to inform the adaptation of an evidence-based smoking cessation intervention developed for Spanish-speaking Hispanic and Latino individuals from a printed format into a mobile app.

METHODS: Guided by a user-centered approach and in collaboration with product design industry experts, wireframes were developed to present the app’s layout and functionality. Focus groups were conducted over Zoom (Zoom Communications) with Spanish-speaking individuals who currently smoke to assess their previous mobile app experience, attitudes toward mobile apps, and feedback on app architecture and design. Two independent reviewers (RB in collaboration with another member from the qualitative core) trained in qualitative methods coded the focus group data using a thematic analysis approach and identified emerging themes.

RESULTS: The app wireframes included 4 navigation buttons on the home screen to organize and deliver evidence-based intervention content-Home (Inicio), Learn (Aprende), My Coach (Mi Couch), and Profile (Perfil). Different wireframe designs were generated in distinct color palettes. Data saturation was reached after three focus groups. Participants were 54% (7/13) women, had a mean age of 56 (SD 14.9) years, 39% (5/13) had an education ≤high school, and 31% (4/13) were married or cohabitating. All participants smoked daily, a mean of 14 (SD 7.8) cigarettes per day, for 32 (SD 16.9) years, and 54% (7/13) smoked ≤30 minutes of waking. Participants reported using social media, news, shopping, and gaming apps, but few used mobile health apps. Salient barriers for app use included worries regarding privacy breaches and fears about misinformation. Desired features included community-building elements, personalization, reward badges, knowledge checks, and audiovisual presentation of content within the app. Participants disliked having a countdown to quit date, preferring an “I quit” button to initiate monitoring progress. They also viewed sharing progress with support networks as a source of unwanted pressure, although a few saw it as motivational. Overall, participants liked the app design and indicated willingness to use it.

CONCLUSIONS: This formative research provides critical insights into preferences related to the development of culturally tailored mobile smoking cessation interventions for Spanish-speaking individuals. Key findings highlighted enthusiasm for a smoking cessation app and the importance of including features that foster social connection and allow for personalization.

PMID:42155124 | DOI:10.2196/84249

JMIR Med Inform. 2026 May 19;14:e84916. doi: 10.2196/84916.

ABSTRACT

BACKGROUND: This exploratory study investigated the impact of computer use on physician performance during clinical simulations. Standardized patient (SP) scenarios used in family practice certification examinations were adapted to include the use of the electronic health record (EHR).

OBJECTIVE: The goal was to compare the impact of EHR use during simulated virtual patient encounters on resident physicians’ and staff physicians’ patient-centeredness (PC) and overall clinical performance, as well as to measure the cognitive load (CL) imposed by EHR use.

METHODS: Sixteen participants each completed 2 video telemedicine simulations with SPs. One simulation case included limited past medical history for the SP in the EHR, while the other did not. Participants were instructed to completely document the encounter using the EHR. Participants’ self-perceived CL was measured using the raw National Aeronautics and Space Administration Task Load Index (NASA-TLX). Video recordings were analyzed for participant PC and overall clinical performance. In addition to interacting with the EHR, multiple participants also conducted internet searches. The proportion of time that participants spent interacting with the computer, either using the EHR or searching the internet, was calculated. Inductive qualitative coding of a subset of video recordings (18 of 32 encounters) was performed, with a focus on signs of stress/CL. All videos were assessed for usability problems.

RESULTS: Staff physicians (n=6) scored higher on PC compared to resident physicians (n=10) for both cases, though differences were not statistically significant after correction for multiple comparisons (family-wise error rate). Physicians’ overall CL, as measured by the raw NASA-TLX, was not significantly correlated with computer use. Exploratory qualitative data analysis found both verbal and nonverbal signs of stress/CL due to computer use while interacting with the SPs. The proportion of time displaying nonverbal signs of stress/CL was calculated for a subset of participants (6 resident physicians and 3 staff physicians). Participant interpretations of instructions to completely document the encounter using the EHR varied widely. It is likely that participants’ usual style of documenting, either primarily during or after patient encounters, impacted their use of the EHR while SPs were present.

CONCLUSIONS: Use of the computer during video telemedicine appointments may negatively impact physician PC and overall clinical performance. Exploratory qualitative coding identified both verbal and nonverbal signs of stress/CL when participants interacted with the computer and the patient simultaneously. Increased clinical experience helped to mitigate the negative impact of computer use. If the use of the EHR is included in physician certification examinations, clear instructions regarding which tasks must be completed in the EHR during interactions with SPs should be provided.

PMID:42155120 | DOI:10.2196/84916

JMIR Med Educ. 2026 May 19;12:e84942. doi: 10.2196/84942.

ABSTRACT

BACKGROUND: Artificial intelligence (AI) tools have revolutionized various aspects of education and health care in recent years. Their influence extends across multiple domains of medical education, from traditional learning to research and foreign language acquisition.

OBJECTIVE: This study aims to evaluate the experiences and perceptions of AI tools usage in a low-resource setting and identify the factors influencing their adoption.

METHODS: A cross-sectional study was conducted to evaluate the experiences with AI tools and perceptions regarding their future applications in education and health care among medical students in Syria. The sample was equally divided between clinical-year students and graduates. Chi-square tests analyzed differences based on demographics and experience, while Mann-Whitney U tests compared group perceptions of AI’s future role. Factors studied included academic year, gender, German language learning, computer access, and research experience.

RESULTS: Among 400 participants, AI tools were widely used for study preparation (228/400, 57% of participants), assignments (160/400, 40% of participants), and research. Clinical students used AI more than graduates for examination preparation (P<.001), creating cases (P=.03), and writing tasks (P<.001). Males used AI more for research (P=.004) or anatomy (P=.02); German learners relied on AI for language tasks. Despite 76% (304/400) of students believing AI would enhance residency training and 71.8% (287/400) of students supporting institutional policies, only 25.5% (102/400) of students expected career benefits. Ethical concerns were higher among females and researchers.

CONCLUSIONS: This study highlights the increasing reliance on AI tools among medical students and graduates for academic and clinical purposes. The highest usage was reported in study preparation, writing tasks, and clinical simulations. Significant differences in AI usage were observed based on academic level, gender, access to technology, and research experience. While perceptions were largely positive, concerns remained around ethical use, potential job displacement, and diminished human interaction in medicine. These findings underscore the importance of developing institutional policies to guide the ethical and effective integration of AI in medical education.

PMID:42155108 | DOI:10.2196/84942

JMIR Form Res. 2026 May 19;10:e91021. doi: 10.2196/91021.

ABSTRACT

BACKGROUND: Clinical decision-making training in operative dentistry commonly relies on real or standardized patients to develop undergraduate students’ ability to deliver safe, effective, and patient-centered care. However, training with real or standardized patients can be limited in scalability, cost-effectiveness, and accessibility. Large language models, with their human-like language capabilities, may have the potential to simulate patients in clinical encounters and help overcome some limitations associated with traditional training approaches.

OBJECTIVE: This study aimed to evaluate the feasibility of using large language model-based standardized virtual patients to support undergraduate dental students’ clinical decision-making training in operative dentistry.

METHODS: This mixed methods cross-sectional feasibility study was conducted during a simulation-based clinical decision-making training session in the Operative Dentistry and Cariology course at the College of Dentistry, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia. Eligible participants were second-year undergraduate dental students enrolled in the course. A convenience sampling approach was used, with all eligible students (N=50) invited to participate. A total of 41 students completed the study, 23 (56%) of whom were male. The students were divided into 8 groups. Each group interacted with 2 standardized virtual patients powered by ChatGPT-4o (OpenAI) through the Chatbase platform to complete comprehensive history-taking and then reviewed the standardized virtual patients’ intraoral photographs and bitewing radiographs. For each standardized virtual patient, students as a group recorded diagnoses, performed a risk assessment, and formulated a treatment plan. Students then completed the Student Satisfaction and Self-Confidence in Learning questionnaire. The quality of the standardized virtual patient responses and overall dialogue realism were evaluated using the Dialogue Authenticity Scale. The dialogues were also thematically analyzed to identify authenticity-undermining response features and explore their context and underlying causes.

RESULTS: Students perceived the simulation-based training session positively, with all questionnaire items showing high median scores (4.00-5.00 on a 5-point scale), and both item-level IQRs and 95% CIs spanning no more than 1.0 scale point. In addition, standardized virtual patient responses were largely authentic, with an overall median authenticity rating of 4.50 (IQR 4.00-5.00; 95% CI 4.00-5.00) on a 6-point scale across all interactions. However, several authenticity-undermining response features were identified, including responses that were inconsistent with typical human behavior, contained information beyond a patient’s likely knowledge, or were factually incorrect.

CONCLUSIONS: This proof-of-concept study supports the feasibility of implementing large language model-based standardized virtual patients in undergraduate simulation-based clinical decision-making training in operative dentistry. In a dental context where this application has been only minimally evaluated, this study provides early evidence of positive student perceptions, acceptability, and largely authentic dialogue, while also identifying important performance limitations. Further research is warranted to optimize performance and to evaluate the educational effectiveness of this approach in improving undergraduate students’ clinical skills and knowledge.

PMID:42155101 | DOI:10.2196/91021