Nevin Manimala

N Z Med J. 2025 Dec 12;138(1627):36-41. doi: 10.26635/6965.7126.

ABSTRACT

AIM: To quantify the current state of the cardiology specialist workforce in Health New Zealand – Te Whatu Ora.

METHODS: The Cardiac Society of Australia and New Zealand sent a survey to all Health New Zealand – Te Whatu Ora cardiology departments in 2024, requesting information on specialist cardiac staff. Population information was obtained from Health New Zealand – Te Whatu Ora. International comparisons were obtained by website search.

RESULTS: Of 154 Health New Zealand – Te Whatu Ora-employed cardiologists, 119 (77%) were male, and 113 (73%) received cardiology training in New Zealand. Over half were aged >50, 35% >55, including 18% >60 years. Time in current position was 12±9 years and the vacancy rate was 14%. The current ratio of persons per cardiologist is 35,000. In the five districts with the highest proportion of Māori and Pacific peoples, this ratio exceeds the national average: Tairāwhiti 54,000; Counties Manukau 38,000; Lakes 61,000; Northland 52,000; Hawke’s Bay 47,000. For cities with cardiac surgery the ratio is 32,000 and without is 46,000. International ratios include: United States of America (USA) 15,000; Canada 25,000; United Kingdom (UK) 40,000 and Australia 25,000 persons per cardiologist.

CONCLUSIONS: Health New Zealand – Te Whatu Ora has an experienced but ageing cardiologist workforce, with many vacancies. Districts with higher Māori/Pacific populations have fewer cardiologists per capita than the national average of 1:35,000, which is similar to the UK, but less than the USA, Australia and Canada.

PMID:41380122 | DOI:10.26635/6965.7126

JMIR Med Inform. 2025 Dec 11;13:e77891. doi: 10.2196/77891.

ABSTRACT

BACKGROUND: Acute care use (ACU) represents a major economic burden in oncology, which can ideally be prevented. Existing models effectively predict such events.

OBJECTIVE: We aimed to quantify the cost savings achieved by implementing a model to predict ACU in oncology patients undergoing systemic therapy.

METHODS: This retrospective cohort study analyzed patients with cancer at an academic medical center from 2010 to 2022. We included patients who received systemic therapy and identified ACU events occurring after treatment initiation, excluding those with known death dates within the study period. Data on ACU-related expenses were gathered from Medicare claims and mapped to service codes in electronic health records, yielding average daily costs for each patient over 180 days following the start of therapy. The exposure was an ACU event.

RESULTS: The main outcome was the average daily cost per patient at the end of the first 180 days of systemic therapy. We observed that expense accumulation flattened earlier and more rapidly among non-ACU patients. This study included 20,556 patients, of whom 3820 (18.58%) experienced at least 1 ACU. The average daily cost per patient for those with and without ACU was US $94.62 (SD US $72.54; 95% CI US $92.32-$96.92) and US $53.28 (SD US $59.92; 95% CI US $52.37-$54.19), respectively. The average total cost per ACU and non-ACU patient was US $17,031.92 (SD US $13,056.63; 95% CI US $16,616.74-$17,445.09) and US $9591.06 (SD US $10,785.83; 95% CI US $9427.64-$9754.48), respectively. To estimate the long-term financial impact of deploying the predictive model, we conducted a cost-benefit analysis based on an annual cohort size of 2177 patients. In the first year alone, the model yielded projected savings of US $910,000. By year 6, projected savings grew to US $9.46 million annually. The cumulative avoided costs over a 6-year deployment period totaled approximately US $31.11 million. These estimates compared the baseline cost model to the intervention model assuming a prevention rate of 35% for preventable ACU events and an average ACU cost of US $17,031.92 (SD US $13,037).

CONCLUSIONS: Predictive analytics can significantly reduce costs associated with ACU events, enhancing economic efficiency in cancer care. Further research is needed to explore potential health benefits.

PMID:41380118 | DOI:10.2196/77891

Blood Adv. 2025 Dec 11:bloodadvances.2025018527. doi: 10.1182/bloodadvances.2025018527. Online ahead of print.

ABSTRACT

The benefit of rituximab maintenance after first-line (1L) bendamustine and rituximab (BR) in patients with mantle cell lymphoma (MCL) remains uncertain, with inconsistent results from the phase 2 MAINTAIN trial and several retrospective studies. We conducted a large retrospective study at 27 US and Canadian academic centers to examine the benefit of rituximab maintenance after BR. A total of 911 patients received 1L BR between 2010-2020, and 703 had an objective response and no evidence of disease progression at the 3-month post-BR landmark. Among those, 394 (56%) received rituximab maintenance and 309 (44%) did not, with largely similar baseline patient and disease characteristics. In the landmark analysis, rituximab maintenance was associated with improved event-free survival (EFS, median 49.9 vs 29.7 months, P < 0.001) as well as overall survival (OS, median 109.5 vs 74.2 months, P < 0.001). The EFS and OS benefits were observed across most of the subgroups. EFS and OS differences were statistically significant in those who achieved a complete response to 1L BR (n=590; median EFS 62.7 vs 31.1 months, P < 0.001; median OS 136.1 vs 75.3 months, P < 0.001), but the analysis in those who achieved a partial response to 1L BR was limited by the small sample size. These results provide additional evidence for the survival benefit of rituximab maintenance after BR in MCL and support its use in clinical trial design and routine practice.

PMID:41380101 | DOI:10.1182/bloodadvances.2025018527

Interact J Med Res. 2025 Dec 11;14:e65538. doi: 10.2196/65538.

ABSTRACT

BACKGROUND: Digital interventions for obesity have demonstrated efficacy in obesity prevention and management. The emergence of smartphones and ubiquitous apps such as WeChat represents potential modality to enhance the reach, sustainability, and cost-effectiveness of such interventions. By the end of the first quarter of 2024, WeChat had approximately 1.36 billion monthly active users, accounting for 96.5% of China’s population. The use of this platform for obesity interventions has been validated in multiple Chinese trials, most published in Chinese language journals.

OBJECTIVE: We aim to synthesize the existing evidence on obesity interventions delivered through WeChat to generate implications for future intervention design and development, thereby reaching an international audience.

METHODS: We conducted a scoping review of PubMed and China National Knowledge Infrastructure using search terms including “WeChat,” “obesity,” “weight,” “BMI,” “waist circumference,” “hip circumference,” “waist-to-hip ratio,” “body fat,” “skin fold thickness,” and these Chinese equivalents “weixin,” “feipang,” “tizhong,” “tizhongzhishu,” “yaowei,” “tunwei,” “yaotunbi,” “tizhi,” and “pizhehoudu.” We included only original research studies, theses, or dissertations with measurable outcomes that used WeChat functions as intervention strategies. Study quality was assessed using the National Institutes of Health Quality Assessment Tool, with specific tools selected based on study design. Descriptive statistics were applied, with categorical variables summarized as frequencies and percentages (n, %) to report study distribution.

RESULTS: Our scoping review based on PubMed and China National Knowledge Infrastructure identified 665 initial records, among which 43 studies met eligibility criteria and were included for data extraction to characterize intervention details. Results indicated effectiveness in 86.0% (37/43) of studies, with WeChat-assisted obesity interventions achieving significant short- and long-term weight loss measured by objective outcomes (body weight, BMI, waist circumference, hip circumference, waist-to-hip ratio, and body fat percentage). However, formative research informing intervention design was insufficient. Common methodological limitations included lack of randomization and blinding (42/43, 97.7%) and unreported intervention compliance metrics (39/43, 92.0%). Functionally, interventions primarily used “WeChat group” and “Official Account”-public accounts that provide health education, diet or physical activity logging, and other features.

CONCLUSIONS: Overall, WeChat represents a promising platform for obesity interventions; however, current apps fail to leverage its full features (eg, online payment and live streaming). Key limitations include methodological heterogeneity and cultural specificity, which were addressed through narrative synthesis stratified by study types. Future research should incorporate the formative phase and use more rigorous methodologies such as randomized controlled trials to optimize intervention design and delivery via this modality.

PMID:41380084 | DOI:10.2196/65538

West J Emerg Med. 2025 Oct 9;26(6):1702-1709. doi: 10.5811/westjem.29333.

ABSTRACT

INTRODUCTION: Firearm injuries have become increasingly more common in the pediatric population; however, there is a paucity of literature examining the management of these pediatric firearm-related injuries (FRI) specifically as they affect the upper extremity. This study identifies demographic and environmental risk factors in pediatric upper extremity FRIs and evaluates the severity of injury, concomitant injuries, and rates of surgical intervention in pediatric patients treated at a Level I pediatric trauma center over 20 years.

METHODS: We completed a retrospective analysis on 540 patients <18 years of age with FRIs at a single institution from 2001 – 2020. Of these, 72 (13%) had FRIs involving the upper extremity. The patients were stratified into groups based on whether they had received operative intervention or a bedside procedure for their injury and on their year of presentation between two decades (2001 – 2010 vs. 2011 – 2020). We obtained upper extremity injury-specific variables along with hospital demographics. The primary outcomes in this study included hospital length of stay, number of bullet wounds, motor and sensory deficits, and amputation.

RESULTS: In the last 10 years, the rate of upper extremity FRIs observed in the pediatric population has increased by 380% at our institution (15 vs. 57, P < .001). After 2010, cases were more likely to present with an increased number of gunshot wounds per patient (1.14 vs. 1.98, 95% confidence interval [CI] -0.94 – 0.24, P = .03) but were less likely to require admission to the intensive care unit (19% vs. 67%, P < .001). When stratifying by intervention, both the operative intervention and bedside procedure groups had a similar number of gunshot wounds (1.86 vs 1.76, 95% CI -0.52 – 0.43, P = .86). The operative intervention group was more likely to have had a soft tissue injury (68% vs. 35%, P = .005) and motor deficit at follow-up (45% vs.15%, P =.02). Patients in the operative intervention group had longer lengths of stay (9.66 vs. 2.25 days, 95% CI -1.16 – -0.21, P < .01) and more morbid injuries despite similar patient demographics.

CONCLUSION: In the last decade, an increased frequency of pediatric upper extremity firearm-related injuries was noted despite a stagnant state population. Emphasis should continue to be placed on education and improving firearm safety in settings in which children are present.

PMID:41380079 | DOI:10.5811/westjem.29333

West J Emerg Med. 2025 Oct 22;26(6):1679-1687. doi: 10.5811/westjem.43528.

ABSTRACT

INTRODUCTION: Most patients with acute coronary syndrome (ACS) die before hospitalization. Early diagnosis and effective interventions can prevent the disease from worsening. In this single-center, retrospective study we aimed to investigate the appropriateness of the pretreatment of patients referred to the emergency department of our hospital, a percutaneous cardiac intervention (PCI) center, with a prediagnosis of ACS under the previously published European Society of Cardiology guidelines (2017 and 2020) and the new guidelines published in 2023.

METHODS: Based on the date of publication of the European Society of Cardiology’s most recent ACS guidelines (August 25, 2023), we divided patients admitted between August 25, 2022-August 24, 2024, into two groups: patients who were evaluated and received pretreatment under the previous guidelines; and patients who were evaluated and received pretreatment under the new guidelines.

RESULTS: Of 1,675 patients screened for enrollment who were referred to our PCI center with prediagnosis of ACS, after exclusion criteria, we report on 1,450 (86.6%). Pretreatment (before PCI) compliance rate with all aspects of the previous and new guidelines was low, at 9.8%. Study patients were 69.9% (n = 1,013) male with mean age of 63.9 ± 13.0 years. Comparing the compliance rate between the new versus previous guidelines, for individual components, we found better compliance for aspirin administration (72.6 vs. 66.2%) and anticoagulants (40.3 vs. 22.7%), while for P2Y12 inhibitors, we found lower compliance (58.9 vs. 70.0%, all p< .001). For the subset of patients with ST-elevation myocardial infarction, P2Y12 inhibitors were used less appropriately under the new vs. previous guidelines (31.4 vs. 55.0%, p < .001).

CONCLUSION: The compliance rates with the previous and new guidelines for ACS pretreatment by physicians working in hospitals without PCI centers were low. Pretreatment compliance during the new guideline period was lower than compliance during the prior guideline period.

PMID:41380077 | DOI:10.5811/westjem.43528

West J Emerg Med. 2025 Nov 26;26(6):1744-1754. doi: 10.5811/westjem.41507.

ABSTRACT

INTRODUCTION: Delirium is a critical neuropsychiatric condition that surged among older adults during the coronavirus disease 2019 (COVID-19) pandemic, likely due to social isolation resulting from distancing measures. In this study we examined trends in delirium-related emergency department (ED) visits before and during the pandemic using nationwide data from South Korea, with a focus on different phases of social distancing, to inform healthcare strategies for older adults during public health crises.

METHODS: We obtained data from the National Emergency Department Information System (2017-2022). Changes in ED visits were assessed across pre-pandemic (January 2017-January 2020), early pandemic (February 2020-March 2022), and late pandemic (April 2022-December 2022) phases using interrupted time series analysis.

RESULTS: A total of 80,442 delirium-related ED visits among adults ≥ 65 years of age were recorded. The interrupted time series analysis showed a significant step increase in ED visits during the early pandemic phase (relative risk [RR] 1.290, 95% CI 1.201-1.386; 29.0% increase), followed by a decrease in the late pandemic phase (RR 0.922, 95% CI 0.868-0.981; 7.8% decrease). The most substantial increase was for individuals 65-74 year of age during the early pandemic period (RR 1.406, 95% CI 1.264-1.564) reflecting a 40.6% increase in visits to the ED. Indirect ED visits, such as institutional referrals, also notably increased (RR 1.275, 95% CI 1.184-1.373) reflecting a 27.5% increase.

CONCLUSION: Delirium-related ED visits among older adults showed a notable 7.8% decrease during the late pandemic period, with key risk groups identified, particularly adults 65-74 of age (40.6% increase) and those referred from institutions (27.5% increase) during the early pandemic period. These findings may help inform targeted interventions and public health responses in similar healthcare settings. Despite limitations including reliance on diagnostic codes, lack of subgroup analysis by COVID-19 status, potential duplicate visit counts, and limited regional granularity this study offers important insight into delirium care needs during crisis periods. Further research should further explore causal mechanisms and the specific impact of COVID-19 infection on delirium incidence.

PMID:41380075 | DOI:10.5811/westjem.41507

Cornea. 2025 Dec 5. doi: 10.1097/ICO.0000000000004065. Online ahead of print.

ABSTRACT

PURPOSE: To assess the effect of surgical decision making on the type of corneal crosslinking (CXL) protocol in eyes with keratoconus (KC) based on stromal thickness maps and thinnest corneal pachymetry (TCP).

METHODS: A prospective, nonrandomized cohort study was performed between January 2022 and January 2023. Patients were allocated to Epi-off or transepithelial CXL (TE-CXL) procedures depending on the TCP value using Scheimpflug. TCP ≥450 μm was used to designate patient’s eye to the Epi-off CXL procedure and TCP <450 μm to TE-CXL. On the same day, a combined Placido and Anterior Segment OCT evaluation was performed to assess epithelial thickness (ET) and minimum stromal thickness (MinST). The type of surgery was then finally selected: Epi-off CXL was indicated when MinST ≥400 μm, whereas TE-CXL procedure was indicated when MinST <400 μm. We assessed the percentage of cases in which MinST data changed the surgical decision (Utility).

RESULTS: The study included 245 eyes, MinST was 407.26 ± 50.92 (range 223-497). Stromal thickness maps assessed before surgery altered the surgeon’s decision making in 5.30% (13 out of 245) of cases. The procedure was changed from Epi-off to TE-CXL and from TE-CXL to Epi-Off in 3.67% and 1.63% of the cases, respectively.

CONCLUSIONS: Anterior segment optical coherence tomography stromal thickness maps have minimal impact on the surgical decision making for conventional Epi-off and TE-CXL protocols. Considering that MinST data provide objective information on stromal thickness, unlike TCP, and avoid the need for deepithelialization, their implications in sub-400 protocols may be greater.

PMID:41379517 | DOI:10.1097/ICO.0000000000004065

J Surg Orthop Adv. 2025 Winter;34(4):203-206.

ABSTRACT

The purpose of the study was to determine the relationship between increased body mass index (BMI) and tibial prosthesis characteristics. A retrospective analysis of total knee arthroplasties (TKAs) was completed, and a Cox multivariate regression was performed. In total, 8,548 TKAs were completed, and cumulative survivability was 98.0% at 5 years and 97.1% at 10 years. Age < 70 years (p < 0.01), male sex (p < 0.01), and BMI ≥ 40 kg/m2 (p = 0.04) were significantly related to revision in all implants. Implant type, contact surface area, base plate surface area, and tibial stem length did not have a statistically significant effect on implant survivability (p = 0.62 – 0.91). When stratified based on BMI, there was a significant decrease in survivability for those BMI ≥ 40 kg/m2 (p < 0.01). Patients with high BMI do not necessarily require larger implants, and surface area and stem length do not affect survivability. Patient factors appear to drive survivability outcomes after primary TKA more than the implant factors. (Journal of Surgical Orthopaedic Advances 34(4):203-206, 2025).

PMID:41379512

J Surg Orthop Adv. 2025 Winter;34(4):193-195.

ABSTRACT

The purpose of this study was to quantify femoral rotation in the axial plane for posterior-stabilized total knee replacements performed with a modified gap-balancing technique. In total, 2442 knees were selected from a computer-assisted orthopaedic surgery navigation system database. The knees were stratified into three groups based on preoperative coronal plane alignment. The computer navigation recorded distal femoral and tibial resection angles, and the rotational position of the femoral component. Means were calculated for each of the three groups. There was substantial variation of femoral axial rotation in all three groups. In aggregate, the mean rotational position for all knees was 2.4° external (-10.2° – 20.9°). The mean rotation for the varus group was 2.5° (-9.8° – 15.7°), 2.5° (-9.8° – 20.9°) for the neutral group, and 1.1° (-10.2° – 9.9°) for the valgus group (p < 0.0001). The data indicates that choosing a predetermined rotational position for the femoral component may lead to flexion gap asymmetry more frequently than by adjusting the rotational position intraoperatively to achieve a rectangular flexion space. This is the first study to quantify differences between varus and valgus knees related to flexion gap stability. Correlation of these findings to clinical outcomes is needed. There is no single rotational position for the femoral component that will produce a balanced flexion gap for every knee. There is a statistically significant difference between mean rotational position for femoral components for varus and valgus knees. (Journal of Surgical Orthopaedic Advances 34(4):193-195, 2025).

PMID:41379510