Nevin Manimala

JAMA Netw Open. 2025 Dec 1;8(12):e2546865. doi: 10.1001/jamanetworkopen.2025.46865.

ABSTRACT

IMPORTANCE: Sodium-glucose cotransporter-2 inhibitors have emerged as important therapeutic options for heart failure (HF). However, their comparative clinical effectiveness remains uncertain.

OBJECTIVE: To compare the outcomes associated with dapagliflozin and empagliflozin use in patients diagnosed with HF.

DESIGN, SETTING, AND PARTICIPANTS: This cohort study used a clinical data warehouse platform shared by 8 medical centers affiliated with The Catholic University of Korea to screen all patients who were diagnosed with HF between January 2021 and November 2023 at these 8 medical centers. Patients were taking either dapagliflozin or empagliflozin and underwent transthoracic echocardiography. One-to-one propensity score matching was performed to ensure comparable baseline characteristics between groups. The propensity score-matched cohort was stratified by left ventricular ejection fraction (LVEF) into subgroups: HF with reduced ejection fraction group had an LVEF of 40% or lower, HF with mildly reduced ejection fraction group had an LVEF of 41% to 49%, and HF with preserved ejection fraction group had an LVEF of 50% or higher. Statistical analyses were performed from December 2023 to July 2025.

EXPOSURE: All patients received either dapagliflozin or empagliflozin.

MAIN OUTCOMES AND MEASURES: The primary outcome was a composite of cardiovascular death or hospitalization for heart failure. Secondary outcomes included the individual primary outcome components, all-cause death, and cardiovascular hospitalization.

RESULTS: After propensity score matching, the balanced cohort included 4930 patients (2465 each in the dapagliflozin and empagliflozin group; mean [SD] age, 68.8 [13.4] years; 2944 males [59.7%]). The median (IQR) follow-up duration was 16.0 (8.0-27.0) months. In the propensity score-matched cohort, dapagliflozin and empagliflozin showed no significant difference in the primary outcome: a composite of cardiovascular death or HF hospitalization occurred in 9.8% of patients (241 of 2465) taking dapagliflozin vs 9.3% of patients (229 of 2465) taking empagliflozin (adjusted hazard ratio [AHR], 0.99; 95% CI, 0.83-1.19; P = .95). The results did not change after stratifying the cohort by LVEF 40% or lower (14.9% [126 of 844] vs 15.4% [132 of 855]; AHR, 1.06 [95% CI, 0.83-1.35; P = .64]), LVEF 41% to 49% (5.0% [17 of 343] vs 6.3% [22 of 350]; AHR, 1.28 [95% CI, 0.68-2.42; P = .45]), and LVEF 50% or higher (7.7% [98 of 1278] vs 6.0% [75 of 1260]; AHR, 0.80 [95% CI, 0.60-1.09; P = .32]), without between-group heterogeneity (P for interaction = .32). For the secondary outcomes, there were also no significant differences between the dapagliflozin and empagliflozin groups.

CONCLUSIONS AND RELEVANCE: In this cohort study of patients with HF, dapagliflozin and empagliflozin had similar clinical outcomes in HF management. Further research and clinical trials are necessary to validate these findings and inform clinical decision-making.

PMID:41343213 | DOI:10.1001/jamanetworkopen.2025.46865

JAMA Netw Open. 2025 Dec 1;8(12):e2546876. doi: 10.1001/jamanetworkopen.2025.46876.

ABSTRACT

IMPORTANCE: Medicaid eligibility for nursing home care is determined in part by an individual’s (or a couples’, if married) financial resources, including income and assets. To qualify, individuals must “spend down” their resources to meet states’ Medicaid eligibility asset thresholds. Little empirical work has examined the rate of Medicaid spend-down in nursing homes over the past 2 decades.

OBJECTIVE: To identify the rate of spend-down in nursing homes, defined as the share of total residents who began their stay as non-Medicaid enrolled (after accounting for Medicare-covered skilled nursing facility [SNF] days, where applicable) and became Medicaid enrolled before discharge or death.

DESIGN, SETTING, AND PARTICIPANTS: This cohort study used a combination of administrative, enrollment, and claims data from 2018 to 2022 to build a panel of 191 416 US nursing home residents enrolled in traditional Medicare-including those admitted for postacute and long-term care-who newly entered a facility in 2018 and either stayed beyond their Medicare SNF days or did not have any Medicare-covered SNF days. Statistical analysis was performed from July 2024 to October 2025.

EXPOSURE: Newly entering a nursing home in 2018 as non-Medicaid enrolled.

MAIN OUTCOMES AND MEASURES: The main outcome was whether an individual spent down their assets and became enrolled in Medicaid during their nursing home stay. Multivariate regression was used to identify factors associated with spend-down.

RESULTS: The study included 191 416 individuals (mean [SD] age at time of admission, 81.0 [11.4] years; 58.0% women; mean [SD] time in nursing home, 331.0 [485.8] days) with traditional Medicare who newly entered a nursing home in 2018, of whom 33.9% either began their stay as Medicaid enrolled or enrolled in Medicaid after the completion of their Medicare-covered SNF days. The remaining 66.2% of individuals were initially not enrolled in Medicaid on admission or after the completion of their Medicare-covered SNF days. Of those who were initially not Medicaid enrolled, 16.4% spent down their assets during their stay and enrolled in Medicaid (mean [SD] time to spend-down, 6.1 [7.9] months). The likelihood of spend-down increased with length of stay and was higher among Black, Hispanic, North American Native, and younger residents.

CONCLUSIONS AND RELEVANCE: In this cohort study of nursing home residents, those who entered a nursing home as initially non-Medicaid enrolled, especially those with longer stays, were at risk of spending down their assets and enrolling in Medicaid. This finding raises concerns both about individuals impoverishing themselves because of the high cost of care and the long-term financial sustainability of the Medicaid program.

PMID:41343212 | DOI:10.1001/jamanetworkopen.2025.46876

JAMA Netw Open. 2025 Dec 1;8(12):e2546883. doi: 10.1001/jamanetworkopen.2025.46883.

ABSTRACT

IMPORTANCE: Limited evidence exists concerning access to abortion facilities from Native lands. To address this gap, travel times from Native lands to abortion facilities before and after the Dobbs v Jackson Women’s Health Organization (Dobbs) decision were compared.

OBJECTIVE: To compare travel times to abortion facilities from Native lands before and after the Dobbs decision.

DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study, conducted from July 1, 2023, to September 30, 2025, measured the proportion of Native lands served by abortion facilities (coverage) and the minimum travel times to abortion facilities. For coverage, the census-designated Native lands (N = 650) within and outside 30-, 60-, and 90-minute drive times to an abortion facility were quantified. For minimum travel, the drive times from Tribal headquarters (N = 577) and Native land population-weighted centroids (N = 650) to the nearest facility were estimated.

MAIN OUTCOMES AND MEASURES: The primary outcomes were the estimates of the median travel time from Native lands to the nearest abortion facility and the pre- and post-Dobbs differences in the contiguous US. Primary analyses compared median drive times in the contiguous US before and after Dobbs. The pre-Dobbs period included facilities active in 2021, while the post-Dobbs period excluded facilities in states with total abortion bans (n = 14) or total or 6-week bans (n = 16) in effect as of October 31, 2023. For Alaska and Hawaii, Euclidean distance was estimated to account for varied travel modes; because no such bans were imposed, pre- and post-Dobbs differences were not examined.

RESULTS: Across 650 Native lands, with an estimated 950 991 female residents of reproductive age (15-44 years), less than half (289 [44.5%]) were within a 90-minute drive of any abortion facility after Dobbs. In the contiguous US, the median drive time significantly increased from 65.5 minutes (IQR, 31.9-103.1 minutes) before Dobbs to 72.3 minutes (IQR, 32.5-147.3 minutes) (total bans only) and 74.0 minutes (IQR, 32.6-152.4 minutes) (total and 6-week bans) after Dobbs. The median distance was 470.1 km (IQR, 270.7-665.9 km) in Alaska and 63.1 km (IQR, 22.9-179.1 km) in Hawaii, where 56.4% of Native lands (31 of 55) required travel to a different island.

CONCLUSIONS AND RELEVANCE: This cross-sectional study of access to abortion facilities from Native lands found that individuals on Native lands faced disproportionately long travel times to abortion facilities, which became longer after Dobbs. Addressing these inequities is critical for advancing health equity for Indigenous communities.

PMID:41343211 | DOI:10.1001/jamanetworkopen.2025.46883

JAMA Netw Open. 2025 Dec 1;8(12):e2547104. doi: 10.1001/jamanetworkopen.2025.47104.

ABSTRACT

IMPORTANCE: Pediatric obesity rates are rising, and adverse childhood experiences (ACEs) may contribute by promoting stress-induced weight gain. Few studies have examined the association of ACEs with body mass index (BMI) and youth-reported protective factors, particularly among Latinx and Hispanic youths, who face higher rates of ACEs and obesity.

OBJECTIVE: To evaluate the association of ACEs with BMI in a population-based cohort and determine whether youth-reported protective factors (eg, self-coping skills, caregiver or friend support, or overall support) moderate this association, with a focus on Latinx and Hispanic youths.

DESIGN, SETTING, AND PARTICIPANTS: This large, cross-sectional study of youths aged 11 to 12 years was conducted using year 2 data (July 2018 to March 2020) of the Adolescent Brain Cognitive Development (ABCD) study, a prospective, 10-year longitudinal, 21-site dataset comprised of a population-cohort of US youths. Data were analyzed between August 2024 and March 2025.

EXPOSURES: Cumulative ACEs (12 categories) and youth-reported protective factors (4 categories).

MAIN OUTCOME AND MEASURES: The primary outcome was the ability of self-reported protective factors to moderate the hypothesized association of ACEs with BMI in Latinx and Hispanic youths. Linear mixed-effects models explored associations of ACEs, protective factors, and ethnicity (ie, Latinx and Hispanic or non-Hispanic) with BMI, while controlling for confounders (eg, sex, age, puberty, and socioeconomic status).

RESULTS: There were 5435 youths with available data at ages 11 to 12 years (1141 Latinx and Hispanic [21.0%]; 2636 female [48.5%]; mean [SD] age, 143.1 [7.6] months). Compared with non-Hispanic youths, Latinx and Hispanic youths had greater BMI (mean [SD], 22.1 [5.0] vs 20.3 [4.6]; P < .001) and more ACEs (mean [SD], 2.1 [1.7] vs 1.7 [1.7]; P < .001). Across all youths, ACEs were significantly associated with BMI, with a 0.431 BMI increase for every 1.7-point increase (1 SD) in ACE score. In Latinx and Hispanic youths only, self-coping (β = -0.74; 95% CI, -1.03 to -0.46; P < .001), caregiver support (β = -0.38; 95% CI, -0.66 to -0.11; P = .006), and overall protective score (β = -0.55; 95% CI, -0.61 to -0.06; P < .001) moderated the association of ACEs with BMI.

CONCLUSIONS AND RELEVANCE: These findings highlight the clinical importance of early ACE screening to identify at-risk youths for targeted, trauma-informed weight management interventions, and gather support for the cultivation of resiliency-focused skills like self-coping and caregiver support. Pediatric obesity is a pressing public health issue, and these strategies hold potential to alter weight trajectories, which may improve health outcomes and reduce health disparities.

PMID:41343209 | DOI:10.1001/jamanetworkopen.2025.47104

J Glob Health. 2025 Dec 5;15:04326. doi: 10.7189/jogh.15.04326.

ABSTRACT

BACKGROUND: Most medical research on pneumonia in children focuses on those <5 years, leaving a gap in understanding pneumonia in children aged 5-9. We aimed to identify the characteristics of children from this age group who had pneumonia and required hospital care, including critical care service.

METHODS: In this retrospective chart analysis, we examined clinical, demographic, and laboratory characteristics of children aged 5-9 years with clinical and radiologic pneumonia admitted to Dhaka Hospital, International Centre for Diarrhoeal Disease Research, Bangladesh, from 2011 to 2020. We categorised the children into two groups: those who required critical care (admitted to the intensive care unit (ICU)) and those who did not. We compared the two groups to identify factors independently associated with the need for critical care using a log binomial regression model.

RESULTS: Among a total of 154 children who fulfilled the enrolment criteria, 34 were admitted to the ICU requiring critical care, and 120 children were treated in the inpatient ward, as they did not require any critical care. The median age of the children requiring critical care was 69 (interquartile range (IQR) = 60-81) months, compared to 72 (IQR = 62-84) months for those who didn`t require critical care (P = 0.259). Using a log binomial regression model we found hypoxemia (odds ratio (OR) = 10.1; 95% confidence interval (CI) = 1.42-71.92, P = 0.021), convulsion (OR = 281.37; 95% CI = 12.99-6091.72, P < 0.001], sepsis (OR = 27.69; 95% CI = 3.33-230.39, P = 0.002), hypokalaemia (OR = 10.37; 95% CI = 1.40-76.96, P = 0.022) were the independently associated with critical care service among children aged five to nine with pneumonia.

CONCLUSIONS: Our results suggest that early recognition and prompt treatment of hypoxemia, convulsions, sepsis, and hypokalaemia may significantly reduce the need for critical care and possibly avert fatal consequences in children with pneumonia, aged 5-9, especially in resource-limited settings.

PMID:41343207 | DOI:10.7189/jogh.15.04326

Am J Speech Lang Pathol. 2025 Dec 4:1-16. doi: 10.1044/2025_AJSLP-25-00141. Online ahead of print.

ABSTRACT

PURPOSE: The Speech Assessment of Children’s Home Language(s) (SACHL) offers a new, evidence-based clinical protocol for speech-language pathologists (SLPs) to assess speech in unfamiliar languages. This study used implementation science to investigate SLPs’ current multilingual speech assessment practices, determine the prospective acceptability of the SACHL, and compare current confidence to prospective confidence with the SACHL.

METHOD: The Consolidated Framework for Implementation Research and the Theoretical Framework of Acceptability were used to explore innovation deliverers’ (SLPs and student SLPs) prospective acceptability of the innovation (SACHL). Attendees at in-person and online SACHL presentations were invited to participate. A total of 360 participants responded to an online questionnaire exploring current practices, transcription skills, confidence, and acceptability of the SACHL. Statistical tests compared attendees at different presentations, SLPs and student SLPs, and monolingual and multilingual participants.

RESULTS: The majority of participants indicated low current confidence in assessing multilingual children. Most SLPs assessed, transcribed, and analyzed multilingual children’s speech in English but rarely or never applied these practices in children’s home language(s). The majority of participants rated the SACHL as being culturally responsive, well designed, and easy to understand and that it could increase diagnostic accuracy. There were concerns around the time burden in using the SACHL. Most (87.45%) indicated they would like to use the SACHL in clinical practice, and there was a statistically significant improvement between current confidence and prospective confidence.

SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.30716981.

PMID:41343205 | DOI:10.1044/2025_AJSLP-25-00141

J Glob Health. 2025 Dec 5;15:04291. doi: 10.7189/jogh.15.04291.

ABSTRACT

BACKGROUND: Globally, the issue of ischaemic heart disease (IHD) has emerged as a prominent public health challenge in the ongoing process of ageing. Previous assessments relied upon data constrained by geographical scope and lacking a thorough worldwide evaluation. We aimed to present the incidence, prevalence, death, and disability-adjusted life years (DALYs) due to IHD at global, regional, and national levels from 1990 to 2021, emphasising decomposition and progressive analysis. We aim to provide relevant information to guide health policy decisions, allocate medical resources effectively, and improve patient care protocols for greater efficiency.

METHODS: We aimed to accurately depict the health impact of IHD by applying standardised Global Burden of Disease approaches and analysing four key epidemiological indicators: prevalence, incidence, mortality, and DALYs. We quantified temporal trends in the burden of IHD from 1990 to 2021 using the estimated annual percentage change (EAPC) metric. We conducted an in-depth examination of global trends, categorising them by age group, gender, and the sociodemographic index (SDI) to provide a more nuanced understanding. Decomposition analyses of IHD DALYs, which examine the effects of age distribution, population dynamics, and changes in disease patterns, enabled us to accurately quantify the specific contributions of each factor to the overall IHD burden. Using frontier analytical methods, we intended to pinpoint the minimal plausible burden of IHD, contingent on the level of development, as gauged by the SDI.

RESULTS: In 2021, the age-standardised incidence rate (ASIR) of IHD decreased compared with 1990 (EAPC = -0.44; 95% confidence interval = -0.47, -0.42). Moreover, the age-standardised mortality rates (ASMR) and DALYs (ASDR) decreased over time. The overall IHD burden was marginally higher in males than in females. The global rates for prevalence, incidence, deaths, and DALYs related to IHD demonstrated an overall rising trend along with age. Among all regions, the North Africa and Middle East region exhibited the highest ASIR (ASIR = 895.85; 95% uncertainty interval (UI) = 786.65, 1043.49) and age-standardised prevalence rate (ASPR) (ASPR = 6404.84; 95% UI = 5872.02, 7041.08) for IHD in 2021. Central Asia recorded the highest ASMR (ASMR = 265.51; 95% UI = 240.67, 290.42) and ASDR (ASDR = 4864.49; 95% UI = 4415.55, 5338.75) in 2021. Decomposition analysis revealed population growth and ageing as primary factors driving the rise in IHD DALYs. Frontier analysis illuminated ample room for enhancement across the entire development continuum.

CONCLUSIONS: The variability in IHD burden is influenced by gender, age, and geographic location. The global burden of IHD has persistently increased during the last three decades, notably among older males. The escalating ageing population and demographic expansion underscore the importance of bolstering public health measures and optimising resource allocation, particularly in etiological investigation, prompt diagnosis, preventive measures, and locally tailored management for IHD.

PMID:41343197 | DOI:10.7189/jogh.15.04291

J Glob Health. 2025 Dec 5;15:04359. doi: 10.7189/jogh.15.04359.

ABSTRACT

BACKGROUND: With declining funding for population-based household surveys, routine health facility data offer a promising alternative for tracking newborn health and service quality. However, their utility depends on data quality. We assessed the quality of ten data elements within routine health information systems in the Central African Republic (CAR), Ethiopia, Tanzania, and Uganda, seven of which align with the Every Newborn Action Plan core newborn indicators.

METHODS: We conducted a cross-sectional study in 97 emergency obstetric and newborn care facilities across 4 countries between November 2022 and July 2024. We extracted three months of routine register and summary report data on ten maternal and newborn elements (two denominators, three outcome numerators, five newborn care interventions) and one tracer maternal indicator. We evaluated data quality on four dimensions (availability, completeness, accuracy, and internal consistency) and measured internal consistency using the ratio of (total births – live births)/stillbirths, with a value of 1 suggesting ideal internal consistency.

RESULTS: Denominator completeness exceeded 90% in Uganda and Tanzania, but was lower in the CAR (87%) and Ethiopia (82%). Impact numerator completeness averaged 79% for neonatal mortality and 81% for low birth weight, with Ethiopia performing worst, with scores of 45% and 32%, respectively). Completeness for newborn interventions (early breastfeeding, kangaroo mother care, bag-mask ventilation, sepsis management) remained below 90%, with the CAR lacking neonatal sepsis data and Ethiopia lacking early breastfeeding data. Accuracy was poor: concordance between register recounts and summary reports ranged from 9% to 40%. Internal consistency checks revealed mismatches in 80% of facilities, including negative ratios in Uganda and ratios >1 in the CAR.

CONCLUSIONS: Significant gaps in completeness, accuracy, and internal consistency undermine the reliability of newborn and stillbirth data in routine health information systems, highlighting a need for their strengthening, the integration of standardised newborn indicators, and institutionalized quality verification processes to ensure timely, reliable, and actionable data for improving newborn care.

PMID:41343194 | DOI:10.7189/jogh.15.04359

JAMA Otolaryngol Head Neck Surg. 2025 Dec 4. doi: 10.1001/jamaoto.2025.4203. Online ahead of print.

ABSTRACT

IMPORTANCE: Historical evidence demonstrated that delays or interruptions in radiotherapy (RT) are associated with poorer oncologic outcomes in head and neck squamous cell carcinoma (HNSCC). Substantial concerns arose during the COVID-19 pandemic, when treatment schedules were frequently disrupted.

OBJECTIVE: To determine the association of RT interruptions with locoregional failure (LRF) and overall survival (OS).

DESIGN, SETTING, AND PARTICIPANTS: This retrospective review and secondary analysis of 3 randomized clinical trials (NRG/RTOG 0129, 0522, and 1016) included patients enrolled in the trials who were treated with RT. Patients with HNSCC were grouped as (1) p16-positive oropharynx (p16+ OPSCC) and (2) p16-negative oropharynx and all other subsites regardless of p16 status (called locally advanced HNSCC [LAHNSCC])). Cox proportional hazards models were fit to assess the association of an RT interruption (binary model) and length of RT interruption (continuous model) with LRF and OS.

EXPOSURES: Presence of RT interruption.

MAIN OUTCOMES AND MEASURES: LRF and OS.

RESULTS: There were 1549 patients (200 female patients [12.9%]; mean [SD] age, 57 [6] years; 1048 p16+ OPSCC [67.7%]; 501 LAHNSCC [32.3%]) who were included in the binary model; 439 (28.3%) had RT interruption. There were 1083 patients (69.9%) with available length of RT interruption (continuous model). A binary RT interruption was associated with hazard ratios (HRs) of 1.04 (95% CI, 0.90-1.36) for LRF and 1.22 (95% CI, 0.99-1.50) for OS. As a continuous predictor, each 7-day interruption corresponded to HRs of 1.45 (95% CI, 1.12-1.89) for LRF and 1.41 (95% CI, 1.07-1.86) for OS. Analyses did not indicate effect modification by p16 status, and results are presented from models that estimated the effect of RT interruption across both groups. Using covariate-adjusted predictions from models that included clinical and tumor characteristics, a mean 7-day interruption in RT was associated with a 3-year LRF decrement of 4.1% in p16+ OPSCC and 9.1% in LAHNSCC. Predicted 3-year LRF detriment due to RT interruption ranged from 2.0% for a patient with non-T4, non-N3, p16+ OPSCC to 11.2% for a patients with LAHNSCC with a T4N3 p16-negative cancer.

CONCLUSIONS AND RELEVANCE: The secondary analysis suggests that RT treatment interruptions may be negatively associated with LRF and OS in HNSCC, but the magnitude of the association varies depending on p16 status and clinical characteristics. While treatment interruptions should globally be discouraged, patients with LAHNSCC or higher-stage disease may be most affected.

TRIAL REGISTRATION: ClinicalTrials.gov Identifiers: NCT00047008; NCT00265941; NCT01302834.

PMID:41343184 | DOI:10.1001/jamaoto.2025.4203

J Glob Health. 2025 Dec 5;15:04319. doi: 10.7189/jogh.15.04319.

ABSTRACT

BACKGROUND: Evidence regarding the association between physical activity (PA) and diabetic retinopathy (DR) remains inconsistent. Furthermore, its effects on retinal vessel diameters in type 2 diabetes are not well established. We aimed to investigate the relationship between PA, DR, and retinal vessel diameters, explore underlying mechanisms, and identify protective exercise regimens.

METHODS: We included patients with type 2 diabetes from the Shanghai Cohort Study of Diabetic Eye Disease. Retinal vessel diameters were measured using computer vision and deep learning. Anthropometric data were collected using standard methods, and PA data through interviews. In 2017, participants were categorised by their DR status. Those without DR were divided into active and inactive groups and followed for three years to assess the effect of PA. For statistical analyses, we used independent t-tests, χ² tests, one-way analysis of variance, Bonferroni tests, multiple linear and logistic regression models, Kaplan-Meier, and Cox regression models.

RESULTS: In the cross-sectional analysis, we analysed a sample of 42 992 individuals, with a mean age of 64.42 (standard deviation (SD) = 6.87) years. PA was associated with reduced odds of moderate and severe non-proliferative DR, and with wider retinal arterioles and venules. In the longitudinal cohort, we analysed 3669 individuals, with a mean age of 63.1 (SD = 6.65) years. PA was a protective factor against incident DR (hazard ratio = 0.812; 95% confidence interval = 0.679-0.971) and was associated with increased peripheral retinal arteriolar calibre and arterio-venous ratio.

CONCLUSIONS: PA improved retinal vessel diameters and lowered DR incidence, highlighting the necessity for further research into the physiological mechanisms linking PA and DR. Promoting awareness and engagement in moderate/high-intensity exercise may enhance diabetes health management.

REGISTRATION: ClinicalTrials.gov NCT03665090.

PMID:41343177 | DOI:10.7189/jogh.15.04319