Nevin Manimala

JAMA Pediatr. 2026 Mar 23. doi: 10.1001/jamapediatrics.2026.0335. Online ahead of print.

ABSTRACT

IMPORTANCE: Sleep behavior markedly shifts in adolescence, increasing vulnerability to mental health disorders. Although sleep health is understood to be multidimensional, adolescent-specific sleep health dimensions have not been empirically validated and their relevance to transdiagnostic mental health outcomes is unknown.

OBJECTIVE: To identify sleep health dimensions using Fitbit devices in a large sample of young adolescents and assess concurrent and prospective associations between sleep health dimensions and transdiagnostic mental health outcomes.

DESIGN, SETTING, AND PARTICIPANTS: Multicenter longitudinal cohort study using data from 3393 participants in the Adolescent Brain Cognitive Development (ABCD) Study (Data Release 5.1, collected 2018-2020), including early adolescents (ages 11-13 years) within the US. Exploratory factor analysis (EFA) was used to identify sleep health dimensions and confirmatory factor analysis (CFA) to confirm the factor structure in an independent subsample. Linear mixed-effects models were used to test concurrent and prospective associations between sleep dimensions and mental health outcomes at 1-year follow-up. Statistical analysis was conducted from January to November 2025.

EXPOSURES: Objective sleep data collected for up to 21 (range, 7-21) days, using wearable Fitbit devices.

MAIN OUTCOMES AND MEASURES: Transdiagnostic mental health outcomes assessed via the Child Behavior Checklist and Brief Problem Monitor (internalizing and externalizing symptoms), Prodromal Questionnaire-Brief Child Version (psychoticlike symptoms), and 10-item Mania Scale (mania symptoms).

RESULTS: The 3393 participants (49% female; median age, 12 years) were split into EFA and CFA subsamples. Six sleep factors were identified using EFA: irregularity, timing, social jetlag, duration, weekend oversleep, and continuity. CFA confirmed this factor structure. All variables loaded strongly (≥0.64) onto at least 1 factor (factor 1 loadings, 0.64-0.98; factor 2, 0.96-0.98; factor 3, 0.95-0.97; factor 4, -0.86 to 1.01; factor 5, 0.68-0.93; factor 6, 0.82-0.94). Greater sleep irregularity was associated with transdiagnostic mental health symptoms cross-sectionally, but not prospectively (β, 0.06 [95% CI, 0.02-0.10] to 0.12 [95% CI, 0.08-0.16]). Shorter duration was associated with total, internalizing, externalizing, and attention symptoms cross-sectionally (β, -0.06 [95% CI, -0.10 to -0.01] to -0.11 [95% CI, -0.15 to -0.06]) and total, attention, and psychotic symptoms 1 year later.

CONCLUSIONS AND RELEVANCE: In this study, wearable Fitbit data provide empirical support for multidimensional frameworks of sleep health in adolescence. Although effect sizes were small, sleep irregularity and duration emerged as key dimensions with relevance to mental health. These findings establish a foundation for future investigations, including examining within-person patterns of the 6 dimensions, extending to older adolescence, investigating associations with other health outcomes, replicating with research-grade actigraphy devices, and suggesting potential targets for pediatric sleep interventions.

PMID:41870441 | DOI:10.1001/jamapediatrics.2026.0335

JAMA Netw Open. 2026 Mar 2;9(3):e262790. doi: 10.1001/jamanetworkopen.2026.2790.

NO ABSTRACT

PMID:41870432 | DOI:10.1001/jamanetworkopen.2026.2790

JAMA Netw Open. 2026 Mar 2;9(3):e261922. doi: 10.1001/jamanetworkopen.2026.1922.

ABSTRACT

IMPORTANCE: Physicians with disabilities face bias and barriers in the workplace, including stigma, lack of accommodations, and mistreatment, which may contribute to workforce attrition. Given the projected physician shortage and the importance of physicians with disabilities in providing informed and empathetic care, understanding attrition within this group is critical.

OBJECTIVE: To examine the associations among disability, workplace accommodations, and physician workforce attrition, including consideration of leaving medical practice and reductions in clinical hours.

DESIGN, SETTING, AND PARTICIPANTS: This survey study used a cross-sectional design to analyze data from the 2022 National Sample Survey of Physicians. Logistic regression models assessed associations between disability and attrition outcomes, adjusting for demographic and workplace factors. Participants included 5917 active physicians who self-reported personal (eg, disability status) and professional (eg, accommodations) data. Data were collected from May 10 to November 9, 2022, and analyzed from October 1, 2023, to May 1, 2025.

MAIN OUTCOMES AND MEASURES: The primary outcomes were (1) having considered leaving medical practice within the past 12 months, including reasons why, and (2) having ever reduced clinical hours for 6 months or longer. The core independent variable was accommodation status.

RESULTS: Among the 5917 physicians surveyed, 154 (2.6%) reported having a disability. A total of 3707 respondents (62.6%) were men or transgender men and 5620 (95.0%) identified as heterosexual; the mean (SD) age was 53.9 (10.8) years. Fifty-six physicians with disabilities (36.4%) considered leaving the practice of medicine, compared with 1316 of 5600 physicians (23.5%) without disabilities. Sixty-seven physicians with disabilities (43.5%) reported transitioning to part time or pausing their practice at some point, compared with 1327 (23.7%) without disabilities. Multivariate regression analysis found physicians with disabilities were more likely than their peers without disabilities to consider leaving medical practice (odds ratio [OR], 2.22; 95% CI, 1.24-3.96; P = .01) and to have reduced clinical hours or paused practice during their careers (OR, 1.94; 95% CI, 1.09-3.43; P = .02). Burnout was the most common reason among both groups, and physicians with disabilities more frequently cited underlying health conditions (self or family) (32 [52.7%] vs 122 [8.5%]). Among physicians with disabilities, those who received accommodations were significantly less likely than those without accommodations to report an intent to leave (42 of 123 [34.3%] and 13 of 24 [54.2%], respectively).

CONCLUSIONS AND RELEVANCE: In this survey study, physicians with disabilities were significantly more likely to consider leaving the workforce and to reduce clinical hours than their peers without disabilities. Clear, stigma-free disclosure and accommodation processes, along with inclusive workplace cultures, are essential to retaining this vital segment of the physician workforce.

PMID:41870431 | DOI:10.1001/jamanetworkopen.2026.1922

JAMA Netw Open. 2026 Mar 2;9(3):e262725. doi: 10.1001/jamanetworkopen.2026.2725.

ABSTRACT

IMPORTANCE: Paternal psychiatric disorders during the perinatal period can affect the health of the entire family; however, these conditions have often been underrecognized, and little is known about their incidence and timing of onset.

OBJECTIVE: To investigate incidence patterns of new-onset diagnosed psychiatric disorders among men in Sweden before, during, and after a partner’s pregnancy.

DESIGN, SETTING, AND PARTICIPANTS: This prospective cohort study used linked national register data for all fathers of children born in Sweden between January 1, 2003, and December 31, 2021, with follow-up from 1 year before to 1 year after pregnancy. Data were analyzed from October 1, 2024, to March 31, 2025.

EXPOSURES: The time during pregnancy and 1 year after childbirth (post partum) were considered the risk periods, while 1 year before pregnancy (before conception) was used as the reference period.

MAIN OUTCOMES AND MEASURES: Annual and weekly incidence rates (IRs) of clinical diagnoses of any psychiatric disorder and 9 type-specific disorders were calculated and standardized by age and calendar year. Adjusted Poisson regression analysis was used to further estimate incidence rate ratios (IRRs) of psychiatric disorders during and after pregnancy compared with before conception.

RESULTS: This study included 1 915 722 births from 1 096 198 fathers (mean [SD] age at childbirth, 33.8 [6.2] years) in Sweden. IRs of any diagnosed psychiatric disorder were lower during pregnancy (eg, pregnancy week 1: IR, 5.50 [95% CI, 4.69-6.31] per 1000 person-years) and the early postpartum period (eg, postpartum week 1: IR, 5.19 [95% CI, 4.41-5.97] per 1000 person-years) than in the corresponding preconception weeks (eg, preconception week 1: IR, 7.00 [95% CI, 5.97-8.04] per 1000 person-years); they returned to comparable rates later post partum. This pattern was also observed for IRRs of anxiety, alcohol use, and drug use (ie, the use of nonalcohol, nontobacco psychoactive drugs) disorders. IRRs of depression (eg, postpartum weeks 45-49: IRR, 1.30 [95% CI, 1.12-1.52]) and stress-related disorders (eg, postpartum weeks 45-49: IRR, 1.36 [95% CI, 1.15-1.61]), however, showed a notable 30% increase toward the end of the first postpartum year. In contrast, IRRs of diagnosis of tobacco use disorder, attention-deficit/hyperactivity disorder, bipolar disorder, or psychosis remained relatively stable before, during, and after pregnancy.

CONCLUSIONS AND RELEVANCE: In this nationwide cohort study, fathers in Sweden were less likely to be diagnosed with a psychiatric disorder during a partner’s pregnancy and early post partum than before conception, but IRs returned to comparable levels thereafter. These incidence patterns may reflect transient protection and delayed detection during the transition to fatherhood and support the need for paternal mental health surveillance, particularly for increased depression and stress-related disorders in the late postpartum period.

PMID:41870430 | DOI:10.1001/jamanetworkopen.2026.2725

JAMA Netw Open. 2026 Mar 2;9(3):e262750. doi: 10.1001/jamanetworkopen.2026.2750.

ABSTRACT

IMPORTANCE: Large language models (LLMs) are increasingly applied to mental health contexts, yet their capacity to generate responses that align with evidence-based psychotherapy remains uncertain. Motivational interviewing (MI), a structured counseling approach, provides an empirically grounded setting for evaluating alignment between LLM-generated and human therapist responses.

OBJECTIVE: To evaluate how closely an LLM’s responses align with therapist responses in MI sessions, using automated similarity metrics.

DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study used high-fidelity therapist-client transcripts annotated with the Motivational Interviewing Treatment Integrity system. Transcripts were sourced from publicly available counseling videos. For each therapist turn, the GPT-4o LLM generated a response using a standardized, MI-informed prompt based on the preceding conversation context. Analyses were conducted between March and May 2025.

MAIN OUTCOMES AND MEASURES: Alignment between LLM-generated and therapist responses was assessed using (1) cosine similarity based on sentence embeddings to capture semantic overlap and (2) DeepEval, a contextual deep-learning-based metric assessing coherence and contextual appropriateness. A therapist topic-consistency index quantified within-session thematic coherence and was examined as a moderator of alignment.

RESULTS: A total of 3706 therapist turns from 154 MI sessions were evaluated. Mean (SD) DeepEval scores were higher than mean (SD) cosine similarity scores (0.72 [0.31] vs 0.29 [0.20]; P < .001), suggesting limited semantic overlap despite greater contextual appropriateness. Therapist topic consistency significantly moderated similarity, where cosine similarity was higher in high-consistency than low-consistency sessions (mean [SD] difference, 0.027 [0.007]; t3706 = 3.987; P < .001), as was DeepEval score (mean [SD] difference, 0.038 [0.010]; t3706 = 3.747; P < .001). Correlation between metrics was negligible (Spearman ρ, -0.01), indicating that they captured distinct aspects of response alignment. LLM performance declined slightly across longer conversations (mean [SD] slope reduction for cosine similarity, -0.0005 [0.0016], and for DeepEval, -0.0005 [0.0022]), with increased verbosity and signs of reduced contextual grounding.

CONCLUSIONS AND RELEVANCE: In this cross-sectional study of 154 MI sessions, prompted LLMs showed general alignment with therapist responses in MI-oriented conversations, as judged by automated similarity metrics. However, limitations in long-range coherence, stylistic alignment, and the use of indirect proxies for therapeutic quality highlight the need for improved prompt design, MI-specific evaluation methods, and clinical validation before integration into mental health care.

PMID:41870428 | DOI:10.1001/jamanetworkopen.2026.2750

JAMA Netw Open. 2026 Mar 2;9(3):e262780. doi: 10.1001/jamanetworkopen.2026.2780.

ABSTRACT

IMPORTANCE: Human papillomavirus (HPV) vaccination prevents several cancers and genital warts, yet adult uptake in Switzerland remains poorly characterized. In addition to demographic factors, understanding how individuals’ knowledge, attitudes, and behaviors (KAB) are associated with vaccine uptake may support strategies to address coverage gaps.

OBJECTIVE: To estimate adult HPV vaccination uptake in Switzerland and evaluate how population-level KAB profiles are associated with vaccination uptake.

DESIGN, SETTING, AND PARTICIPANTS: This nationwide, cross-sectional, population-based survey of adults throughout Switzerland was conducted between September 2023 and September 2024. Adults aged 18 to 45 years were randomly selected from a national residential registry using disproportionate stratified sampling by age, gender, and region. Participants completed a questionnaire on HPV-related KAB, and corresponding HPV immunization data were verified from individuals’ personal vaccination records.

EXPOSURE: Individual KAB responses regarding HPV disease and vaccination, assessed through standardized questionnaires.

MAIN OUTCOMES AND MEASURES: The primary outcome was documented receipt of 1 or more HPV vaccine dose according to vaccination records. Latent class analysis was used to define KAB profiles, and multivariable logistic regression used to assess associations with HPV vaccination.

RESULTS: Of 41 645 valid addresses, 3847 individuals (9.2%) submitted both a questionnaire and a vaccination record and were included in the analysis. Among 3847 participants (2433 women [weighted 49.1%]; 1997 individuals aged 18-26 years [weighted 26.1%]), 27.2% (95% CI, 25.9%-28.6%) had received 1 or more HPV vaccine dose, with uptake varying by age (58.6% [95% CI, 56.2%-60.9%] for those aged 18-26 years vs 16.1% [95% CI, 14.6%-17.8%] for those aged 27-45 years), gender (42.8% [95% CI, 40.6%-45.0%] of women vs 12.2% [95% CI, 10.8%-13.8%] of men), and region. Three KAB profiles were identified: cluster 1 (2280 participants [52.9%]) showed high HPV awareness and perceived importance, cluster 2 (1099 participants [30.9%]) showed moderate knowledge and low perceived risk, and cluster 3 (468 participants [16.2%]) showed high uncertainty. Vaccination uptake was 41.1% (95% CI, 40.9%-41.2%) in cluster 1, 13.6% (95% CI, 13.4%-13.7%) in cluster 2, and 8.1% (95% CI, 7.9%-8.2%) in cluster 3. Lack of practitioner recommendation was the most common barrier to vaccination across profiles.

CONCLUSIONS AND RELEVANCE: In this cross-sectional study of Swiss adults, in addition to demographic factors, distinct KAB profiles were associated with HPV vaccine uptake. Tailored communication strategies that (1) reinforce practitioner engagement, (2) address risk perception and skepticism, and (3) improve informational outreach may help to address remaining coverage gaps.

PMID:41870427 | DOI:10.1001/jamanetworkopen.2026.2780

JAMA Netw Open. 2026 Mar 2;9(3):e263112. doi: 10.1001/jamanetworkopen.2026.3112.

ABSTRACT

IMPORTANCE: There is limited large-scale evidence to guide the optimal mode of birth for patients with moyamoya disease (MMD).

OBJECTIVE: To evaluate whether the mode of birth (cesarean vs vaginal) is associated with stroke risk after childbirth for women with MMD.

DESIGN, SETTING, AND PARTICIPANTS: This cohort study evaluated stroke outcomes up to 3 years after childbirth. A nationwide, population-based analysis was performed using data from the Health Insurance Review and Assessment Service of South Korea. Individuals with MMD from January 1, 2002, to December 31, 2023 were identified. Among 31 750 patients, those with birth-related procedure codes were selected. The study population was restricted to women aged 19 to 49 years, and those with a diagnosis of malignant neoplasm within 3 years before the index date (date of childbirth) were excluded. Data were analyzed from June 11 to September 8, 2025.

EXPOSURE: Mode of birth.

MAIN OUTCOMES AND MEASURES: The primary outcome was any stroke, defined as a composite of ischemic or hemorrhagic stroke. Secondary outcomes included ischemic stroke, hemorrhagic stroke, and transient ischemic attack.

RESULTS: Of 1683 women analyzed (mean [SD] age, 33.6 [7.8] years), 1077 (64.0%) had cesarean births, and 606 (36.0%) had vaginal births. Post partum (3 months), any stroke incidence was 63.49 and 33.33 per 1000 person-years for cesarean and vaginal births, respectively. Multivariable analyses showed no significant risk differences for any stroke by birth mode at 3 months (adjusted hazard ratio [aHR], 0.71 [95% CI, 0.26-1.97]; P = .52) or 3 years (aHR, 0.90 [95% CI, 0.55-1.47]; P = .67). A significant interaction was observed between the mode of birth and the clinical onset type of MMD for the risk of any stroke (interaction P = .04 after Bonferroni correction); the adjusted HR for vaginal vs cesarean birth was 0.10 (95% CI, 0.01-0.79) in the asymptomatic or nonvascular onset subgroup, 1.49 (95% CI, 0.73-3.03) in the ischemic onset subgroup, and 0.94 (95% CI, 0.50-1.77) in the hemorrhagic onset subgroup. Notably, stroke incidence peaked in the early postpartum period (≤6 months: 35.7 per 1000 person-years), decreased at 1 year, and thereafter remained at a similar level.

CONCLUSIONS AND RELEVANCE: In this cohort study of women with MMD, MMD itself was not found to be an absolute indication for cesarean birth; birth planning should be individualized based on obstetric factors and clinical onset type rather than routine preference for cesarean birth. In addition, vigilant monitoring and preventive strategies during the early postpartum period are warranted.

PMID:41870425 | DOI:10.1001/jamanetworkopen.2026.3112

JAMA. 2026 Mar 23. doi: 10.1001/jama.2026.4175. Online ahead of print.

NO ABSTRACT

PMID:41870422 | DOI:10.1001/jama.2026.4175

JAMA Neurol. 2026 Mar 23. doi: 10.1001/jamaneurol.2026.0359. Online ahead of print.

ABSTRACT

IMPORTANCE: Physical inactivity, hypertension, and hyperlipidemia are modifiable cardiovascular risk factors for age-related cognitive decline and dementia. It remains unknown whether exercise training combined with intensive pharmacological reduction of cardiovascular risk factors (IRVR) would have greater benefits on cognitive function than those of exercise or IRVR alone.

OBJECTIVE: To determine the effects of exercise, IRVR, and exercise combined with IRVR on cognitive function in older adults.

DESIGN, SETTING, AND PARTICIPANTS: This single-blind, multicenter randomized clinical trial with a 2 × 2 factorial design and duration of 24 months was conducted at 4 clinical sites in the US. Enrollment began on February 2, 2017; the final study visit was on January 31, 2022. After screening, older adults without dementia and with hypertension, family history of dementia, and/or self-reported subjective cognitive decline were randomized. Data were analyzed from December 2022 through October 2024.

INTERVENTIONS: Participants were randomized with a 1:1:1:1 ratio to aerobic exercise training, IRVR (lowering of systolic blood pressure to <130 mm Hg and serum low-density lipoprotein cholesterol with atorvastatin), IRVR + exercise, and usual care.

MAIN OUTCOMES AND MEASURES: The primary outcome was change in global cognitive function at 24 months from baseline, assessed with the Preclinical Alzheimer Cognitive Composite (PACC) score. Secondary outcomes were changes in the National Institutes of Health Toolbox Cognition Battery (NIHTB-CB) fluid composite score and individual test scores.

RESULTS: A total of 3290 individuals were screened, and 513 older adults (aged 60-85 years) without dementia and with hypertension, family history of dementia, and/or self-reported subjective cognitive decline were randomized. Among 513 randomized participants (mean [SD] age, 68.7 [6.0] years; 323 female participants [63.0%]), 443 completed 24-month visits, and 480 were included in the primary data analysis. For the primary outcome, there were no statistically significant interactions between intervention groups and time of visits (P = .13). At 24 months, PACC scores increased by 0.2 units in the no-exercise group (95% CI, 0.1-0.3) and by 0.3 units in the exercise group (95% CI, 0.2-0.4), with no significant group differences (0.1 units; 95% CI, -0.1 to 0.2; P = .37). PACC scores also increased by 0.3 units in the no-IRVR group (95% CI, 0.2-0.4) and by 0.2 units in the IRVR group (95% CI, 0.1-0.3), with no significant group differences (0.1 units; 95% CI, -0.3 to 0.03; P = .12). Increases in the NIHTB-CB composite score and individual test scores with exercise or IRVR showed similar results.

CONCLUSIONS AND RELEVANCE: In this multicenter randomized clinical trial among older adults with family history of dementia and/or self-reported subjective cognitive decline, exercise, IRVR, or both did not result in statistically significant differences in improvements in cognitive function over 24 months.

TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02913664.

PMID:41870419 | DOI:10.1001/jamaneurol.2026.0359

J Emerg Nurs. 2026 Mar 23:S0099-1767(26)00046-2. doi: 10.1016/j.jen.2026.02.002. Online ahead of print.

ABSTRACT

INTRODUCTION: Emergency visits for sexual assault have surged 1533.0% since 2006. Sexual assault is linked to worsened health outcomes; outcomes worsen without timely care. Sexual assault nurse examiners are specially trained to improve health care services, enhance forensic evidence collection, and amplify rates of prosecution. National standards recommend 24/7 crisis care to preserve forensic evidence and timely treatment of sexual assault patients. A southeastern teaching hospital’s part-time sexual assault nurse examiner program was audited for sexual assault nurse examiner delay length to establish recommendations.

METHODS: This gap analysis used a retrospective chart review of 150 sexual assault nurse examiner cases from 2022 to 2024 to assess care delays. The 150 patients were selected using a random number generator. Data were gathered from Epic, SharePoint, and manual chart review. Sexual assault nurse examiner delays and patients with disruptions in care were identified. Quantitative data were analyzed using descriptive statistics, whereas reasons for delays were categorized and counted. The evaluation project adhered to national protocols and received an institutional review board exemption.

RESULTS: Results showed average delays of 4.54 hours for sexual assault nurse examiner response times, with waits ranging from 0 to 30.7 hours; 6.37% of all 361 sexual assault nurse examiner cases either left or left and returned owing to sexual assault nurse examiner delays.

DISCUSSION: Prolonged wait times risk negative medical, forensic, and psychological outcomes. To improve care, recommendations include expanding staffing, implementing a full-time program, streamlining processes, and achieving 24/7 sexual assault nurse examiner coverage. Delays in sexual assault nurse examiner response are 4 to 5 times standard recommendations, with only 23.33% of cases meeting the 60-minute goal.

PMID:41870417 | DOI:10.1016/j.jen.2026.02.002