Nevin Manimala

JAMA Netw Open. 2025 May 1;8(5):e2512189. doi: 10.1001/jamanetworkopen.2025.12189.

ABSTRACT

IMPORTANCE: A recent increase in state policies targeting gender minority (GM; transgender and gender-diverse) people may affect the mental health of sexual and gender minority (SGM; nonheterosexual and/or GM) people and GM people specifically.

OBJECTIVE: To estimate changes in mental health symptoms associated with enactment of anti-GM state policies among SGM people and GM people specifically.

DESIGN, SETTING, AND PARTICIPANTS: This repeated cross-sectional study used a staggered difference-in-differences analysis to examine the associations between anti-GM policies in the US and mean changes in mental health symptoms among 8733 SGM adults who completed annual questionnaires between April 1, 2020, and June 1, 2023, for The Population Research in Identity and Disparities for Equality (PRIDE) Study, a national, prospective, continuously enrolling online cohort study of SGM adults.

EXPOSURES: Living in a state with 1 or more of the following enacted policies: (1) bathroom restrictions for GM people, (2) sports bans for GM young people participating in school sports, and (3) bans on gender-affirming care for young people.

MAIN OUTCOMES AND MEASURES: Mean levels of anxiety (measured using the 7-item Generalized Anxiety Disorder scale [GAD-7]; total score range, 0-21), depression (measured using the 9-item Patient Health Questionnaire scale [PHQ-9]; total score range, 0-27), and posttraumatic stress disorder (PTSD) symptoms (measured using the 6-item PTSD Checklist scale [PCL-6]; total score range, 6-30). For all 3 scales, higher scores indicate more severe symptoms.

RESULTS: Among all 8733 SGM participants in the sample (median age, 32.5 years [IQR, 26.0-45.0 years]; 2024 cisgender men [23.2%], 2355 cisgender women [27.0%], 2198 gender-diverse adults assigned female at birth [25.2%], 321 gender-diverse adults assigned male at birth [3.7%], 1294 transgender men [14.8%], and 541 transgender women [6.2%]), anti-GM policy enactment was associated with significant increases in anxiety (GAD-7 score, 0.8 points [95% CI, 0.2-1.4 points]) and PTSD (PCL-6 score, 0.8 points [95% CI, 0.1-1.4 points]) symptoms in states that enacted anti-GM policies compared with states that did not but was not associated with significant increases in depression symptoms (PHQ-9 score, 0.6 points [95% CI, -0.1 to 1.4 points]). In the GM subsample (n = 4354), nonsignificant changes in anxiety (GAD-7 score, 0.6 points [95% CI, -0.2 to 1.4 points]), depression (PHQ-9 score, 0.1 points [95% CI, -0.9 to 1.1 points]), and PTSD (PCL-6 score, 0.7 points [95% CI, -0.2 to 1.6 points]) symptoms were observed after policy enactment in states that enacted anti-GM policies compared with states that did not. Gender minority adults had high mental health symptoms across the study period.

CONCLUSIONS AND RELEVANCE: In this study of 8733 SGM adults using difference-in-differences analysis, anti-GM policies were associated with worse mental health symptoms among SGM adults but no changes in mental health symptoms among GM adults. As these policies proliferate, it is important to consider how they may affect mental health.

PMID:40408106 | DOI:10.1001/jamanetworkopen.2025.12189

JAMA Netw Open. 2025 May 1;8(5):e2512198. doi: 10.1001/jamanetworkopen.2025.12198.

ABSTRACT

IMPORTANCE: Life expectancy is a composite health measure reflecting acute and life-course exposures. Identifying conditions behind disparities in life expectancy can guide policy, planning, and financing to battle the most urgent health problems.

OBJECTIVE: To examine the contribution of 33 causes of death to life expectancy disparities, highlighting 2 sets of priority conditions-8 infectious and maternal and child health conditions (I-8) and 7 noncommunicable diseases and injuries (NCD-7).

DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study examined life expectancy disparities in 7 global regions and 165 countries from 2000 to 2021. Western Europe and Canada (hereafter referred to as the North Atlantic) in 2019 were used as a benchmark for life expectancy achievable with advanced health care and living standards. Life expectancy gaps in locations with life expectancy lower than the benchmark were decomposed by cause of death using the Pollard decomposition on the Global Health Estimates from the World Health Organization. Data were analyzed from February to March 2025.

EXPOSURE: Geographic location (countries and regions).

MAIN OUTCOME AND MEASURE: Life expectancy at birth.

RESULTS: In the median country in 2019, the I-8 and NCD-7 together accounted for 80% (IQR, 71%-88%) of the life expectancy gap compared with the North Atlantic. Outside sub-Saharan Africa, the NCD-7 accounted for the largest share of the gap; for example, more than the total life expectancy gap in China, or 5.5 (95% uncertainty bounds [UB], 5.0-6.0) years of a 4.3-year life expectancy gap; and 6.4 (95% UB, 5.9-6.8) years of a 11.5-year gap in India. However, reduced mortality from the I-8 contributed to enormous improvements in sub-Saharan Africa, accounting for 21.4 (95% UB, 20.6-22.2) years of a 31-year gap in 2000 and 11.4 (95% UB, 10.9-11.8) years of a 22-year gap in 2019. India transitioned from having most of the gap accounted for by the I-8 in 2000, or 11.9 (95% UB, 11.0-13.0) years of a 19.6-year life expectancy gap, to having a larger share accounted for by the NCD-7 in 2019.

CONCLUSIONS AND RELEVANCE: This cross-sectional study suggests that a limited number of causes account for most life expectancy disparities. Together with current information on risk factors, interventions, and morbidity not yet reflected in life expectancy, the varying contributions of these causes to gaps in life expectancy can help focus health policy and guide interventions to reduce risk factors and treat conditions.

PMID:40408105 | DOI:10.1001/jamanetworkopen.2025.12198

JAMA Netw Open. 2025 May 1;8(5):e2512209. doi: 10.1001/jamanetworkopen.2025.12209.

ABSTRACT

IMPORTANCE: Postpartum hemorrhage (PPH) remains the leading cause of maternal mortality globally. Although traditional management relies on blood loss quantification, identifying cases resistant to conventional treatment remains challenging, potentially delaying crucial interventions.

OBJECTIVE: To determine the prevalence and clinical implications of PPH that is resistant to treatment showing arterial contrast extravasation on dynamic computed tomography (CT) (PRACE) and its association with intervention requirements.

DESIGN, SETTING, AND PARTICIPANTS: A multicenter retrospective case-control study of PPH cases was conducted at 43 tertiary facilities across Japan, including 30 university hospitals, between January and December 2021. The study included patients with PPH who were either transported to the centers or who delivered there. Data analysis was performed from September 2023 to November 2024.

EXPOSURE: A diagnosis of PPH, defined as blood loss exceeding 2000 mL or requiring more than 10 units of red blood cell transfusion.

MAIN OUTCOMES AND MEASURES: The primary outcome was the prevalence of PRACE and its association with uterine artery embolization (UAE) requirement. Secondary outcomes included risk factors for severe coagulopathy (fibrinogen <150 mg/dL). Odds ratios (ORs) were estimated using multivariable logistic regression to evaluate the association between types of PPH (atonic uterus, tissue, and PRACE) and PPH severity.

RESULTS: Among 352 patients (median [IQR] age, 33.0 [30.0-37.0] years; 211 [60.0%] primiparous), 205 (58.2%) underwent CT scans, with PRACE detected in 58 (32.2%) of evaluable cases. Patients with PRACE had significantly higher total blood loss (median [IQR], 3455 [2000-5070] mL vs 2500 [1500-2650] mL) and greater UAE requirement (50 of 58 patients [86.2%] vs 35 of 122 patients [28.7%]) compared with patients without PRACE. PRACE was the primary factor associated with the need for UAE (OR, 27.74; 95% CI, 10.52-83.14).

CONCLUSIONS AND RELEVANCE: In this retrospective case-control study of patients with severe PPH undergoing dynamic CT, PRACE represented a distinct and common pathology in severe PPH and was associated with the need for interventional procedures. These findings suggest that dynamic CT imaging should be considered as an essential diagnostic tool in managing treatment-resistant PPH cases.

PMID:40408104 | DOI:10.1001/jamanetworkopen.2025.12209

JAMA Netw Open. 2025 May 1;8(5):e2512262. doi: 10.1001/jamanetworkopen.2025.12262.

ABSTRACT

IMPORTANCE: In most countries, children in the same grade can be up to 12 months apart in age, which represents a considerable relative age difference, particularly in the early years. A relative age effect has been frequently reported in the diagnosis and treatment of attention-deficit/hyperactivity disorder and, more rarely, in the diagnosis of other neurodevelopmental disorders. The relative age effect has never been studied for speech therapy, which is frequently prescribed to treat specific language and learning disorders.

OBJECTIVE: To quantify the association of relative age with the initiation of speech therapy.

DESIGN, SETTING, AND PARTICIPANTS: This cohort study used data from the French National Health Data System and included all children born in France between 2010 and 2016 from September of the year of their 5th birthday until July of the year of their 10th birthday or July 31, 2022 (end of study).

EXPOSURE: Children were categorized according to month of birth.

MAIN OUTCOMES AND MEASURES: Risk of speech therapy initiation was estimated using Cox models adjusted for other known risk factors.

RESULTS: In total, 4 188 985 children (mean [SD] age, 5.2 [0.3] years; 50.8% girls) were included. Speech therapy was initiated for 692 086 children (incidence rate, 53.1 per 1000 person-years, 54.5% boys) during a mean (SD) follow-up of 3.1 (1.6) years. Among children of the same schooling level, the risk of initiating speech therapy steadily increased according to quarter and month of birth, with adjusted hazard ratios of 1.51 (95% CI, 1.50-1.52) for children born in the last quarter vs the first quarter and 1.64 (95% CI, 1.62-1.66) for children born in December vs those born in January. The relative age effect observed for speech therapy was of the same magnitude as that observed for methylphenidate in attention-deficit/hyperactivity disorder (positive control outcome). No relative age effect was observed for the initiation of desmopressin for nocturnal enuresis (negative control outcome).

CONCLUSIONS AND RELEVANCE: This cohort study found that among children in the same grade, an age difference of a few months was associated with the frequency of initiation of speech therapy. These findings may be attributable to a mismatch between the expectations of the school system and the relative age and level of maturity of the children or earlier identification of neurodevelopmental disorders in the youngest children in each age group.

PMID:40408103 | DOI:10.1001/jamanetworkopen.2025.12262

Invest Ophthalmol Vis Sci. 2025 May 1;66(5):32. doi: 10.1167/iovs.66.5.32.

ABSTRACT

PURPOSE: Mutations affecting the CRB1 gene produce retinal dystrophies including early onset severe retinal dystrophy/Leber congenital amaurosis (EOSRD/LCA), retinitis pigmentosa (RP), cone-rod dystrophy (CORD), and macular dystrophy (MD). As treatment strategies advance toward clinical translation, there is a need to establish reliable outcome metrics and to better understand the visual deficits associated with CRB1 retinopathies. To this end, we measured visual acuity (VA) and crowding (the disruptive effect of clutter on object recognition), both key functions in spatial vision, using child-friendly computer-based tests, and gold-standard clinical measures.

METHODS: Patients with molecularly confirmed biallelic CRB1 pathogenic variants were compared with age-matched controls (n = 20 in each). Best-corrected visual acuity (BCVA) was measured with both Early Treatment Diabetic Retinopathy Study (ETDRS) and the computerized VacMan procedures (using an unflanked/isolated VacMan target), which also allowed measurement of crowding when surrounding flanker elements were added.

RESULTS: Both acuity and crowding were significantly elevated in individuals with CRB1 retinopathy compared with controls. ETDRS acuity correlated with both the unflanked (r = 0.868, P < 0.001) and flanked VacMan thresholds (r = 0.748, P < 0.001). No statistically significant changes in crowding were observed with respect to CRB1 phenotype (EOSRD/LCA, CORD, or MD) or age of onset.

CONCLUSIONS: This study demonstrates for the first time that individuals with CRB1 retinopathy exhibit elevated crowding in their foveal vision compared with controls. Measuring crowding offers valuable insights into understanding functional visual deficits in CRB1 retinopathy and could be a useful metric for monitoring disease progression and treatment outcomes in inherited retinal diseases.

PMID:40408095 | DOI:10.1167/iovs.66.5.32

JAMA Health Forum. 2025 May 2;6(5):e250820. doi: 10.1001/jamahealthforum.2025.0820.

ABSTRACT

IMPORTANCE: Demographic and policy changes have occurred since the last large, representative study of homeless adults in the 1990s, which may affect health care access and use.

OBJECTIVE: To describe the prevalence of poor health care access and short-term health care and use the Gelberg-Andersen Behavioral Model for Vulnerable Populations to assess the association between changes in homelessness with health care access and short-term care use.

DESIGN, SETTING, AND PARTICIPANTS: This representative survey of adults experiencing homelessness in California from October 2021 to November 2022 used multistage, venue-based, and respondent-driven sampling. Data were analyzed from May 2023 to December 2024.

EXPOSURES: Shelter status (predisposing vulnerable), insurance (enabling), impairment with activities of daily living (ADL; need), and illicit substance use during the previous 6 months (need).

MAIN OUTCOMES AND MEASURES: The study assessed self-reported no prior-year ambulatory care use and prior 6-month unmet health care need, unmet medication need, emergency department (ED) use, and hospitalization. Population prevalence estimates with Wald 95% CIs and multivariable Poisson regressions were calculated to compute prevalence ratios (PRs).

RESULTS: Thirty-two hundred adults completed the survey (mean age, 46.1 [95% CI, 45.3-46.9] years; 1965 cisgender men [67.2%], 1148 cisgender women [31.2%], and 57 transgender and gender queer individuals [1.6%]), of whom 2016 (77.6%) were unsheltered, 2609 (82.6%) were insured, 1056 (34.4%) had an ADL impairment, and 911 (37.1%) reported illicit substance use 3 or more times a week. A total of 1121 (39.1%) reported no ambulatory care use; 765 (24.3%) reported an unmet health care need and 714 (23.3%) an unmet medication need; 1252 (38.9%) used the ED; and 668 (22.0%) were hospitalized. Lack of ambulatory care use (PR, 1.71; 95% CI, 1.51-1.94) and unmet health care needs (PR, 1.19; 95% CI, 1.02-1.40) were more prevalent for those who were unsheltered. Lack of ambulatory care use (PR, 0.63; 95% CI, 0.57-0.70) and unmet health care needs (PR, 0.80; 95% CI, 0.67-0.95) were less prevalent for those with insurance. Unmet health care needs (PR, 2.13; 95% CI, 1.79-2.55), ED use (PR, 1.15; 95% CI, 1.02-1.30), and hospitalization (PR, 1.74; 95% CI, 1.40-2.17) were more prevalent for those with an ADL impairment. Lack of ambulatory care use (PR, 1.46; 95% CI, 1.19-1.79) and unmet health care needs (PR, 1.30; 95% CI, 1.08-1.55) were more prevalent for those who used illicit substances 3 or more times a week.

CONCLUSIONS AND RELEVANCE: This cross-sectional study found that adults experiencing homelessness reported poor access to ambulatory care and a high prevalence of short-term care use, despite high rates of insurance. Changes in homelessness during the past 30 years were associated with worsened health care access and use.

PMID:40408090 | DOI:10.1001/jamahealthforum.2025.0820

JAMA Health Forum. 2025 May 2;6(5):e251424. doi: 10.1001/jamahealthforum.2025.1424.

ABSTRACT

IMPORTANCE: Millions of lower-income Health Insurance Marketplace enrollees were defaulted from zero-premium to positive-premium health plans in 2022, 2023, and 2024. This turnover in zero-premium plans may cause coverage losses by creating administrative burdens that complicate enrollees’ ability to maintain coverage.

OBJECTIVE: To determine how turnover affected Marketplace reenrollment.

DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study used log-linear fixed-effects models including counties in 29 states that used the HealthCare.gov platform from 2022 through 2024.

EXPOSURE: HealthCare.gov enrollees living in a county that experienced turnover that year.

MAIN OUTCOMES AND MEASURES: County-year-level counts of overall reenrollment, automatic and active enrollment, and active reenrollment split by whether enrollees stayed with or switched from their previous plan. We controlled for premium affordability, insurer competition, other county characteristics, and state-by-year policy changes.

RESULTS: The sample consisted of 2159 counties representing roughly 10 million HealthCare.gov enrollees annually in 29 states that used the HealthCare.gov platform from 2022 through 2024. The share of enrollees living in counties exposed to turnover increased from 10.3% to 93.9% from 2021 to 2022 as the American Rescue Plan Act subsidies were implemented. These increases have persisted into 2024. Turnover across insurers was associated with a 7.0% (95% CI, -12.7 to -1.3) decrease in automatic reenrollment. Any turnover was not associated with changes in active enrollment, though it was associated with a 13.4% decrease (95% CI, -17.7 to -9.1) in enrollees choosing to stay with their previous, default plan and a roughly equivalent 15.0% increase (95% CI, 11.5-18.5) in enrollees choosing to switch plans.

CONCLUSIONS: Turnover affects coverage losses by decreasing automatic, passive reenrollment among lower-income enrollees that may not realize they need to start paying premiums to retain coverage that previously did not have a premium. Turnover also nudges returning enrollees to select new plans rather than selecting their previous plans. This likely increases insurer price competition but also may create hassles for enrollees. These findings suggest that coverage losses from turnover in 2026 among lower-income Marketplace enrollees may be particularly large if enhanced subsidies from the Inflation Reduction Act expire.

PMID:40408089 | DOI:10.1001/jamahealthforum.2025.1424

J Physician Assist Educ. 2025 May 22. doi: 10.1097/JPA.0000000000000678. Online ahead of print.

ABSTRACT

INTRODUCTION: This study aimed to evaluate whether physician assistant/associate (PA) students’ sociodemographic factors were predictors of risk for mistreatment. A secondary analysis aimed to evaluate whether sociodemographic features were evenly distributed among respondents who answered mistreatment items.

METHODS: Data originated from the PA Education Association End of Program Surveys (2018, 2019, 2021, and 2022). Independent variables were gender, race, ethnicity, and sexual orientation. Using logistic regression, odds ratios were calculated for 2 separate dependent variables: whether respondents experienced mistreatment and whether respondents completed mistreatment items.

RESULTS: Surveys included 11,461 respondents, 3218 (28.1%) of whom experienced mistreatment; however, 3258 (28.4%) of respondents did not answer any mistreatment items. Analysis showed statistically significant sociodemographic factors for risk for mistreatment, but the model had poor fit (P-value = 0; receiver operating characteristic [ROC] 0.553), possibly related to partial nonresponse bias. Completing mistreatment items was statistically significantly more likely for respondents who indicated they were gay or lesbian (odds ratio [OR] 1.52) or bisexual (OR 1.82) and less likely for respondents who indicated they were male (OR 0.68), sexual orientation “I don’t know/prefer not to answer” (OR 0.65), Hispanic (OR 0.79), or not White (OR 0.49).

DISCUSSION: The sociodemographic factors evaluated were inadequate to predict mistreatment of PA students, but sociodemographic factors were associated with willingness to complete mistreatment questions. Qualitative research is needed to determine why respondents who are male, Hispanic, or not White are reluctant to complete mistreatment questions. Findings could inform survey improvements to more accurately measure health professions student mistreatment.

PMID:40408079 | DOI:10.1097/JPA.0000000000000678

Aesthet Surg J. 2025 May 23:sjaf057. doi: 10.1093/asj/sjaf057. Online ahead of print.

ABSTRACT

BACKGROUND: Very little is known of how urinary symptoms and low back pain related to rectus abdominis diastasis tend to change after reparative surgery.

OBJECTIVES: In this study we aimed to investigate these symptom changes in women who underwent abdominoplasty with diastasis correction, and also provide an overview on quality of life, psychosocial aspects, and patient satisfaction.

METHODS: A total of 78 patients underwent abdominoplasty with diastasis repair and were included in this prospective study. Urinary symptoms and low back pain were evaluated respectively by the International Consultation on Incontinence Questionnaire, Female Lower Urinary Tract Symptoms Modules (ICIQ-FLUTS) and the Roland-Morris questionnaire. The Derriford Appearance Scale (DAS-59) was administered for evaluation of the respondent’s discomfort, as was the BODY-Q for body image and quality of life. Furthermore, the assessment of satisfaction by 3 external surgeons was obtained. Statistical analysis was conducted with Prism 9.

RESULTS: Statistically significant differences between time T0 (preoperative) and T3 (3 months postoperatively) and between time T0 and T12 (12 months postoperatively) were found for the BODY-Q, ICIQ-FLUTS, and Roland-Morris scores. No correlation was found between diastasis width and the difference from T0 to T12 in any of the symptom questionnaires. A correlation between patient and surgeon satisfaction emerged. In just 9 cases the patient was dissatisfied when the expert observer was satisfied. The mean preoperative DAS-59 value of satisfied patients and satisfied surgeons was compared with that of dissatisfied patients and satisfied surgeons, and a statistically significant difference was noted.

CONCLUSIONS: Abdominoplasty with correction of rectus muscle diastasis may improve women’s quality of life. From the patient’s point of view, voiding and incontinence symptoms and back pain tended to improve after surgery regardless of the width of the diastasis.

PMID:40408076 | DOI:10.1093/asj/sjaf057

J Prim Care Community Health. 2025 Jan-Dec;16:21501319251344427. doi: 10.1177/21501319251344427. Epub 2025 May 23.

ABSTRACT

BACKGROUND: The association between social risk and biomarkers of inflammation remains underexplored in low-resource communities, where social risk and levels of inflammation differ from those in industrialized urban centers. This study aims to assess the association between levels of social risk and biomarkers of inflammation in adults residing in remote rural settings.

METHODS: This population-based, cross-sectional study involved 1392 community-dwellers aged ≥40 years. Social risk was assessed using the social determinants of health (SDH) included in Gijon’s Social Familial Evaluation Scale (SFES). Biomarkers of inflammation were measured through the Systemic Immune-Inflammation Index (SII) and the C-Reactive Protein (CRP)/albumin ratio. Both unadjusted and multivariate models were fitted to determine the independent association between SDH and biomarkers of inflammation, treated as dependent variables.

RESULTS: The mean (±SD) age of 1392 study participants was 53.8 ± 11.5 years (59% women). The mean Gijon’s SFES score was 10.1 ± 2.6 points, the mean SII was 451.6 ± 240.5 × 10⁹ L, and the mean CRP/albumin ratio was 0.13 ± 0.29. Unadjusted generalized linear regression models demonstrated direct significant associations between SDH scores and both dependent variables, including SII (β: 6.12; 95% CI: 1.35-10.89) and the CRP/albumin ratio (β: 0.03; 95% CI: 0.01-0.05). These associations remained significant after adjusting for demographics, level of education, and cardiovascular risk factors for both, the SII (β: 7.24; 95% CI: 2.08-12.41) and the CRP/albumin ratio (β: 0.03; 95% CI: 0.01-0.05).

CONCLUSIONS: Social risk is directly associated with biomarkers of inflammation in the study population, suggesting that inflammation may be associated with adverse health outcomes in individuals with high social risk. Study results demonstrate that this association is not only evident in high-income regions but in underserved rural communities as well.

PMID:40408075 | DOI:10.1177/21501319251344427