Nevin Manimala

J Patient Saf. 2026 Jul 14. doi: 10.1097/PTS.0000000000001559. Online ahead of print.

ABSTRACT

OBJECTIVES: To evaluate the association of a templated interhospital transfer (IHT) note on transfer appropriateness and clinical outcomes.

METHODS: We conducted a retrospective, single-center study of 100 IHTs to the Department of Medicine services between May and June 2023. The exposure was the type of documentation at the time of transfer, categorized as templated note, nontemplated note, or no note. The primary outcome was appropriateness of transfer, determined by 2 independent adjudicators using a standardized framework developed as part of the POINT Study. Documentation type by clinical specialty and reason for transfer were assessed, with statistical analyses of clinical outcomes limited to those with an incidence >5% (ie, escalation/downgrade in level of care within 24 h of transfer and 30 d mortality).

RESULTS: Among 100 transfers, 81 (81%) were deemed appropriate and 19 (19%) were deemed inappropriate. Documentation was present in 59%, including templated (35%) and nontemplated notes (24%). IHTs without documentation had the highest appropriateness rate (87.8%, 36/41), compared with templated notes (29/35, 82.9%; P=0.15) and nontemplated notes (66.7%, 16/24; P=0.042). Downgrades were more common in inappropriate transfers with nontemplated notes (50.0%, 4/8) than in appropriate transfers with templated notes (10.3%, 3/29; P=0.012).

CONCLUSIONS: Structured IHT documentation was inconsistently used and did not predict the appropriateness of transfer. Transfers without documentation were most often appropriate, suggesting straightforward cases may not require formal notes. In contrast, nontemplated notes in inappropriate transfers showed high downgrade rates, implying that unstructured documentation may inflate perceived acuity. Further evaluation of documentation strategies is needed to support appropriate transfer decision-making.

PMID:42447403 | DOI:10.1097/PTS.0000000000001559

J Sex Med. 2026 Jul 3;23(8):qdag214. doi: 10.1093/jsxmed/qdag214.

ABSTRACT

BACKGROUND: Human papillomavirus (HPV) is a prevalent sexually transmitted infection that negatively affects women’s psychological, social, and sexual well-being worldwide.

AIM: This study aimed to evaluate the effect of group Acceptance and Commitment Therapy (ACT) counseling on sexual function in women diagnosed with HPV infection.

METHODS: This single-blind randomized clinical trial was conducted on 56 women with HPV infection. Participants were randomly assigned to an intervention group (n = 28) receiving 8 sessions of ACT counseling or a control group (n = 28) receiving routine care. The Female Sexual Function Index (FSFI) questionnaire was administered at baseline, immediately after, and 1 month following the intervention. Descriptive statistics were calculated, and chi-square and independent t-tests were used to examine baseline differences. Longitudinal changes and between-group comparisons were analyzed using Generalized Estimating Equations with an appropriate correlation structure. A P-value of <.05 was considered statistically significant.

OUTCOMES: The primary outcome was the change in overall sexual function score, as measured by the FSFI, across the 3 assessment points.

RESULTS: Participants in the intervention and control groups had mean ages of 35.96 ± 8.53 and 32.48 ± 6.40 years, respectively. The baseline mean FSFI scores were similar between groups (16.06 ± 7.69 vs. 15.86 ± 8.08). Following ACT counseling, the intervention group’s mean FSFI score significantly increased to 20.68 ± 4.58 immediately post-intervention and 20.64 ± 4.29 1 month later, while the control group’s scores decreased slightly to 15.36 ± 8.68 and 14.20 ± 8.83, respectively. Between-group differences were statistically significant both immediately (B = 5.120, P = .002) and 1 month (B = 6.244, P < .001) after the intervention. Improvements were observed in the desire, arousal, satisfaction, and orgasm domains (P < .001), but changes in lubrication and pain were not significant (P < .05).

CLINICAL IMPLICATIONS: Group ACT counseling offers a promising psychotherapeutic approach to improve sexual health and emotional well-being among women affected by HPV infection.

STRENGTHS & LIMITATIONS: Strengths include the randomized design and the use of validated assessment tools, while limitations involve the small sample size, short follow-up period, and restriction to a single geographic location, limiting generalizability.

CONCLUSION: Group Acceptance and Commitment Therapy effectively enhances sexual function and overall quality of life in women with HPV, suggesting its integration into supportive healthcare interventions.

PMID:42447398 | DOI:10.1093/jsxmed/qdag214

J Pediatr Orthop. 2026 Jul 14. doi: 10.1097/BPO.0000000000003407. Online ahead of print.

ABSTRACT

BACKGROUND: In general, the onset of Legg-Calvé-Perthes disease (LCPD) before age 6 is thought to be associated with a good radiographic outcome. Many of these patients, however, still develop a poor outcome with ovoid-to-flat femoral head deformity. Currently, no early-stage prognosticator of outcome exists for patients younger than 6 years at onset. This study investigated whether perfusion MRI (pMRI) obtained in early stages of LCPD correlates with deformity index (DI), epiphyseal index (EI), and sphericity deviation score (SDS). We hypothesized that early-stage femoral head hypoperfusion would correlate significantly with these radiographic outcomes and serve as an early prognosticator.

METHODS: This multicenter study reviewed demographic, pMRI, and radiographic data from patients with LCPD who had disease onset before age 6. Inclusion criteria were pMRI at Waldenström stage I to IIa. DI and EI were evaluated at 2-year follow-up, and SDS at the healed stage. Statistical analyses included Pearson correlation and ROC analysis, with a threshold predictive of SDS >20.

RESULTS: Forty-one femoral heads (37 patients; mean age at onset 5.0±0.9 years) were analyzed with a mean follow-up of 4.1±1.3 years. Mean hypoperfusion was 49±28%. Mean DI was 0.38±0.18, EI was 0.26±0.10, and SDS was 18.2±12.9. Increasing hypoperfusion (%) correlated significantly with greater femoral head deformity, including higher DI (r=0.76), lower EI (r=-0.62), and higher SDS (r=0.64) (all P<0.001). ROC analysis identified 62% hypoperfusion as optimal for predicting SDS >20 (AUC: 0.80; sensitivity 75%; specificity 87%). Using a 60% cutoff point, outcomes were worse above the threshold: DI (0.31±0.16 vs. 0.52±0.14, P=0.002), EI (0.30±0.09 vs. 0.19±0.07, P<0.001), and SDS (11.7±6.1 vs. 26.8±14.6, P=0.001).

CONCLUSIONS: Early-stage femoral head hypoperfusion correlated significantly with radiographic outcomes at 2-year follow-up and at the healed stage in patients with LCPD onset before age 6. A pMRI hypoperfusion threshold of 60% identified femoral heads at a higher risk for femoral head deformity, supporting pMRI as a potential early prognostic marker.

LEVEL OF EVIDENCE: Level III.

PMID:42447391 | DOI:10.1097/BPO.0000000000003407

J Pediatr Orthop. 2026 Jul 14. doi: 10.1097/BPO.0000000000003411. Online ahead of print.

ABSTRACT

BACKGROUND: Surgical procedures that improve motion for slipped capital femoral epiphysis (SCFE) deformity are typically guided by radiographic imaging. However, the specific aspects of the deformity that have the greatest impact on hip functional biomechanics remain unclear. This study investigated the relationship between radiographic parameters and clinical ROM measurements in patients with SCFE to better elucidate which elements of SCFE pathoanatomy have the greatest effect on joint mobility.

METHODS: Patients who underwent in situ pinning for stable SCFE at a single institution between 2013 and 2025 were retrospectively reviewed. Patients were excluded if they had unstable SCFE or underwent a modified Dunn osteotomy or simultaneous bilateral SCFE procedures. Demographics and clinical ROM measurements were obtained from the electronic health record. Radiographic parameters, including the Southwick slip angle (SSA), posterior sloping angle (PSA), percent epiphyseal displacement of Wilson (PED), and alpha angle, were measured on immediate postoperative radiographs. ROM deficits were calculated as the difference between affected and unaffected hips. The relationships between radiographic and clinical ROM variables were quantified using linear regressions.

RESULTS: Seventy-four hips in 69 patients (mean age 12.3±1.5 y, 50.7% male) were included. In 5 patients, ROM data were available for the contralateral, unaffected hip just before a subsequent slip and were used as control measurements for that hip. Overall, PED had the largest effect on ROM. For every 1% increase in displacement, patients lost an average of 2.18 degrees of flexion (P<0.001) and 2.13 degrees of abduction (P=0.001). SSA, PSA, and AP alpha angle had statistically significant effects on internal rotation in flexion (IRF)-a 1-degree increase in each led to a 0.78, 0.81, and 0.74-degree decrease in IRF, respectively (P<0.001 for all). The lateral alpha angle had the smallest impact.

CONCLUSIONS: In children with SCFE, radiographic deformity predicts clinical ROM. PED has the strongest negative association with flexion and abduction, while PSA, SSA, and AP alpha angle have negative associations with IRF. Reconstructive strategies should prioritize correction of these aspects of the SCFE deformity to maximize joint mobility.

LEVEL OF EVIDENCE: Level III-retrospective comparative study.

PMID:42447386 | DOI:10.1097/BPO.0000000000003411

J Cardiovasc Nurs. 2026 Jul 14. doi: 10.1097/JCN.0000000000001363. Online ahead of print.

ABSTRACT

BACKGROUND: Cardiometabolic syndrome is a major global driver of poor outcomes. Behavioral and socioeconomic factors influence outcomes of cardiometabolic syndrome. Conventional risk models often neglect to capture the role of behavioral and socioeconomic characteristics in cardiometabolic syndrome mortality.

OBJECTIVE: We aimed to identify behavioral-socioeconomic phenotypes among adults with cardiometabolic syndrome using a clustering approach and to examine their associations with cardiovascular and all-cause mortality.

METHODS: We analyzed data from 7839 U.S. adults with cardiometabolic syndrome (2005-2018), followed for a median of 87 months. To explore behavioral-socioeconomic patterns, we used hierarchical clustering on factor analysis of mixed data. Survival analyses were performed using Kaplan-Meier curves with log-rank tests to evaluate mortality differences among clusters. Cluster profile differences were assessed to characterize the demographic, behavioral, socioeconomic, and clinical heterogeneity among the identified subgroups.

RESULTS: Three distinct clusters were identified, differing significantly across demographic, socioeconomic, and behavioral characteristics (P < .001 for most comparisons). Cluster 1 comprised younger, socioeconomically deprived, physically active individuals with higher alcohol use and depression prevalence. Cluster 2 included predominantly older women with lower socioeconomic status, multiple comorbidities, and the poorest cardiometabolic profile, showing the highest cardiovascular and all-cause mortality rates (all log-rank P < .001). Cluster 3 represented socioeconomically advantaged, middle-aged men with the most favorable behavioral patterns and the lowest depression prevalence.

CONCLUSION: Behavioral-socioeconomic clustering identified phenotypes with distinct prognoses in cardiometabolic syndrome. The high-risk cluster 2 reflects the cumulative physiological consequences of long-standing adverse behaviors, socioeconomic deprivation, and comorbid disease progression.

PMID:42447384 | DOI:10.1097/JCN.0000000000001363

JMIR Res Protoc. 2026 Jul 14;15:e94797. doi: 10.2196/94797.

ABSTRACT

BACKGROUND: Attention-deficit/hyperactivity disorder (ADHD) is a prevalent neurodevelopmental condition affecting approximately 7% to 8% of children and adolescents, characterized by persistent inattention, hyperactivity, and impulsivity. Adolescence represents a period of heightened vulnerability, during which pharmacological treatments are frequently limited by adverse effects, suboptimal adherence, and partial response. Physical exercise, particularly high-intensity interval training (HIIT), has demonstrated superior effects on inhibitory control and inattention compared with moderate-intensity continuous exercise. However, the repetitive nature and high perceived exertion of traditional HIIT protocols result in poor adherence, especially in individuals with ADHD. Virtual reality (VR)-based exergames have been proposed as a strategy to sustain vigorous physiological demands while maintaining intrinsic motivation. Despite this potential, the existing literature is predominantly limited by passive control conditions, which prevent adequate control for the effects of VR immersion and cognitive engagement, limiting causal inference regarding the specific contribution of physiological exertion.

OBJECTIVE: This paper presents the protocol for a randomized clinical trial designed to evaluate whether an HIIT-based VR exergame produces greater improvements in inhibitory control and inattention symptoms compared with an active, nonexercise VR control condition in adolescents with ADHD.

METHODS: This multisite, parallel-group, single-blind randomized clinical trial will recruit 98 adolescents aged 12 to 17 years with a confirmed diagnosis of ADHD according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, from 2 outpatient centers in Brazil. Participants will be allocated 1:1 to an HIIT-based VR exergame intervention (Move Sapiens) or an active control condition using the same VR platform without vigorous physical exertion. The intervention comprises 20 sessions over 4 weeks delivered in a home-based format following supervised laboratory familiarization. Primary outcomes are Swanson, Nolan, and Pelham Rating Scale version IV inattention subscale scores and go/no-go commission errors. Secondary outcomes include working memory, cognitive flexibility, processing speed, impulsivity, sleep quality, and anxiety symptoms. Analyses will follow an intention-to-treat approach using linear mixed-effects models.

RESULTS: The trial is ongoing. Funding was granted in October 2024. As of April 2026, 58 participants have been enrolled across 2 sites, of whom 46 (79.3%) have completed the full intervention protocol. Data collection is expected to be completed by October 2026, with results anticipated by December 2026.

CONCLUSIONS: This trial will provide controlled evidence on the efficacy of an HIIT-based VR exergame for adolescents with ADHD using an active control condition matched for technological immersion. The design will enable examination of whether vigorous physical exertion beyond VR immersion and digital engagement constitutes an essential active component for improvements in inhibitory control and inattention in this population. If effective, the intervention may offer an engaging, home-based adjunctive treatment option for adolescents with ADHD.

TRIAL REGISTRATION: ClinicalTrials.gov NCT06632249; https://clinicaltrials.gov/study/NCT06632249.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/94797.

PMID:42446902 | DOI:10.2196/94797

JAMA Netw Open. 2026 Jul 1;9(7):e2623057. doi: 10.1001/jamanetworkopen.2026.23057.

ABSTRACT

IMPORTANCE: Timely treatment in colorectal cancer (CRC) may influence the disease course and, thus, outcomes, but optimal delay thresholds remain uncertain. Identifying pathway-specific time-to-treatment initiation (TTI) effects can guide benchmarks and policies for coordinated, timely care.

OBJECTIVE: To evaluate the association between TTI and 3-year metastasis risk in patients with newly diagnosed nonmetastatic CRC undergoing curative-intent surgery, with attention to variation by treatment pathway.

DESIGN, SETTING, AND PARTICIPANTS: This cohort study of insured US patients with nonmetastatic CRC used deidentified administrative claims from Optum’s Clinformatics Data Mart. Eligible individuals were adults aged 40 years or older with incident nonmetastatic CRC diagnosed during January 1, 2017, to December 31, 2021, who underwent curative-intent surgery within 1 year of diagnosis and had continuous coverage 1 year before and after. Data were analyzed June 2025.

EXPOSURES: TTI was defined as days from CRC diagnosis to the first receipt of cancer-directed therapy (surgery, chemotherapy, or radiation). Patients were categorized into 4 treatment pathways: surgery with or without radiation, surgery followed by adjuvant therapy with or without radiation, neoadjuvant therapy followed by surgery with or without radiation, and trimodality therapy (neoadjuvant therapy, followed by surgery, followed by adjuvant therapy with or without radiation).

MAIN OUTCOMES AND MEASURES: The outcome was 3-year cumulative incidence of metastasis. XGBoost identified optimal TTI thresholds, and Fine-Gray models with death as a competing risk evaluated these thresholds and estimated their associations with metastasis.

RESULTS: Among 11 927 patients (mean [SD] age, 70.7 [10.8] years; 6007 women [50.4%]; 1251 Black [10.5%], 7948 White [66.6%]), 4539 (38.0%) had moderate or severe comorbidity. Over 3 years, 1438 patients (12.1%) developed metastasis. Longer TTIs were associated with higher metastasis risk, varying by treatment pathway. For surgery plus adjuvant therapy, TTIs of 4 to 46 days (subdistribution hazard ratio [sHR], 1.27; 95% CI, 1.04-1.55) and 47 days or longer (sHR, 1.55; 95% CI, 1.08-2.23) were significantly associated with increased risk vs zero to 3 days. For surgery followed by radiation, delays of 223 days or longer showed higher risk (sHR, 2.00; 95% CI, 0.95-4.25) than TTI up to 222 days, although these results were not significant. For neoadjuvant therapy plus surgery, TTI of 68 days or longer were associated with higher risk (sHR, 2.66; 95% CI, 1.02-6.94) than TTI up to 67 days. For patients receiving trimodality therapy, there was no association between TTI and risk of metastasis.

CONCLUSIONS AND RELEVANCE: In this cohort study, treatment delays were associated with higher, pathway-specific metastasis risk. These findings support pathway-tailored benchmarks for treatment initiation and highlight the importance of integrated care in reducing delays and improving timely, equitable, cost-effective CRC care.

PMID:42446881 | DOI:10.1001/jamanetworkopen.2026.23057

JAMA Netw Open. 2026 Jul 1;9(7):e2623166. doi: 10.1001/jamanetworkopen.2026.23166.

ABSTRACT

IMPORTANCE: Pembrolizumab plus chemotherapy, with or without bevacizumab, improves overall survival (OS) in advanced cervical cancer (ACC), but platinum choice and bevacizumab use remain discretionary.

OBJECTIVE: To compare OS by platinum agent and bevacizumab use among patients with ACC receiving first-line pembrolizumab plus chemotherapy in a clinical setting.

DESIGN, SETTING, AND PARTICIPANTS: This comparative effectiveness study used a retrospective multinational cohort with propensity score matching in the TriNetX Global Collaborative Network. Participants included adults with ACC (International Statistical Classification of Diseases, 10th Revision, Clinical Modification, code C53) treated between January 1, 2015, and October 31, 2024. Patients with prior cancer or contraindications to bevacizumab therapy were excluded. Matching was performed on age, race and ethnicity, body mass index, smoking status, and prior chemoradiotherapy. Data were analyzed from November 19 to 28, 2024.

EXPOSURES: Cisplatin or carboplatin, with or without bevacizumab, both combined with first-line pembrolizumab plus paclitaxel.

MAIN OUTCOMES AND MEASURES: Two comparisons were analyzed: cisplatin vs carboplatin and bevacizumab vs no bevacizumab. The primary outcome was OS, defined as time from treatment initiation to death from any cause. Secondary outcomes were adverse events of special interest, including fistula, bowel perforation, and pulmonary embolism.

RESULTS: Among the 1931 patients receiving first-line pembrolizumab with paclitaxel (mean [SD] age, 54.0 [13.2] years), 623 matched pairs of cisplatin-treated patients (n = 719) and carboplatin-treated patients (n = 1212) were included. The mean (SD) age was 51.2 (12.7) years for cisplatin-treated patients and 50.8 (12.7) years for carboplatin-treated patients; the median follow-up was 10.8 (IQR, 3.7-18.0) months and 9.9 (IQR, 2.5-17.2) months, respectively. The median OS was 25.1 (IQR, 9.2 to not reached) months in both groups (HR, 0.98 [95% CI, 0.81-1.18]; P = .35). Bevacizumab-treated patients (n = 803) and those not receiving bevacizumab (n = 667) yielded 455 matched pairs. The mean (SD) age was 53.6 (13.3) years in the bevacizumab-treated group and 54.3 (13.3) years in the group not receiving bevacizumab; the median follow-up was 11.3 (IQR, 4.4-18.2) months and 8.4 (IQR, 1.6-15.1) months, respectively. Twelve-month OS was 74.8% (95% CI, 70.4%-79.2%) vs 64.5% (95% CI, 59.8%-69.2%), respectively; 24-month OS was 56.2% (95% CI, 50.9%-61.5%) vs 54.0% (95% CI, 48.7%-59.3%), respectively. No increased risk of fistula (odds ratio [OR], 0.94 [95% CI, 0.63-1.40]; P = .76), bowel perforation (OR, 1.21 [95% CI, 0.52-2.82]; P = .67), or pulmonary embolism (OR, 0.62 [95% CI, 0.38-1.01]; P = .052) was observed.

CONCLUSIONS AND RELEVANCE: In this comparative effectiveness study of patients with ACC in a clinical setting, cisplatin and carboplatin treatment were associated with similar effectiveness when combined with pembrolizumab. Bevacizumab was associated with early OS benefit, which attenuated over time. These findings warrant prospective validation.

PMID:42446878 | DOI:10.1001/jamanetworkopen.2026.23166

ESC Heart Fail. 2026 Jul 14:xvag184. doi: 10.1093/eschf/xvag184. Online ahead of print.

ABSTRACT

BACKGROUND AND AIMS: Acute decompensated heart failure (ADHF) results in high rates of hospitalisation, re-admissions, and mortality, straining healthcare systems. Loop diuretics are crucial for fluid management in ADHF, but optimal dosing and monitoring remain unclear. The 2021 European Society of Cardiology guidelines suggest individualised dosing based on home diuretic use and close urinary sodium monitoring for better decongestion. This study evaluates the effectiveness of a new natriuresis- and urine output-guided protocol at Maastricht University Medical Centre+ (MUMC+) based on these recommendations.

METHODS: This retrospective study compared patients treated with a natriuresis- and urine output-guided protocol, introduced in May 2022, to those receiving standard care before May 2022. The guided protocol involved individualised loop diuretic dosing, regular urine sodium monitoring, and incremental adjustments as needed. Data on demographics, lab values, length of stay, mortality, and re-admission rates were analysed, with statistical adjustments for potential confounders.

RESULTS: The guided protocol was associated with significantly shorter hospital stay (median 6.9 vs. 7.5 days, P=0.029), lower six-month mortality (10.9% vs. 17.9%, P=0.017), and cardiac rehospitalisation rates (26.1% vs. 35.7%, P=0.015). These effects were independent of baseline differences and confounders. At 12 months, the guided protocol group showed sustained association of reduced cardiac rehospitalisation rates and a trend toward lower mortality.

CONCLUSION: This guided AHF protocol was associated with reduced hospital stays, six-month rehospitalisation rates, and mortality. Tailoring individual optimised diuretic therapy for ADHF seems promising, but further research is needed to confirm its long-term benefits.

PMID:42446874 | DOI:10.1093/eschf/xvag184

J Autism Dev Disord. 2026 Jul 14. doi: 10.1007/s10803-026-07416-y. Online ahead of print.

ABSTRACT

BACKGROUND: Wikipedia is a major health information resource, yet little is known about how autism is represented across language editions.

OBJECTIVES: To examine sourcing, framing, editorial dynamics and readership of autism-related Wikipedia pages in six languages (English, Spanish, French, Italian, Norwegian and Georgian).

METHODS: We constructed a corpus of the main autism article in each language and used Python-based pipelines to extract references, revision histories (2004-2024) and monthly pageviews (2020-2024). We conducted descriptive statistics, lexicometric analyses and inductive thematic coding.

RESULTS: Across languages, autism is lexically and thematically framed primarily as a childhood, biomedical condition: child-related terms outranked adult-related terms in all editions, and “neurodiversity” appeared only marginally. Sourcing patterns differed markedly, with English and Italian relying more heavily on journals, French and Spanish on websites, Norwegian on institutional documents and Georgian under-sourced. Pageviews were highly unequal in absolute terms but, once normalised per million speakers, smaller language communities (Georgian, Norwegian and Italian) showed the highest relative demand. These high-demand editions nonetheless had the smallest editorial bases and fewest cumulative edits.

CONCLUSION: Autism-related Wikipedia pages constitute pivotal but uneven knowledge infrastructures. Strengthening adult, lifespan and neurodiversity perspectives and supporting smaller language communities could improve the robustness of online autism information.

PMID:42446867 | DOI:10.1007/s10803-026-07416-y