Nevin Manimala

J Orthop Surg Res. 2025 Jun 17;20(1):597. doi: 10.1186/s13018-025-05935-5.

ABSTRACT

BACKGROUND: The incidence of anterior cruciate ligament (ACL) reconstructions among adolescents, particularly those involved in high-risk sports, has increased. Despite surgical advancements, outcomes remain worse than in adults. This study aimed to assess ACL reconstruction outcomes in patients under 16 years and compared to older patients. The prevalence of high pivoting sports in those undergoing revision or contralateral ACL reconstruction was also analyzed. We hypothesized that younger athletes experience poorer outcomes and higher rates of secondary surgeries.

METHODS: This study evaluated ACL reconstruction outcomes in patients under 16 years (Group 1) and compared them with those over 16 years (Group 2). A retrospective analysis was conducted on patients who underwent primary arthroscopic ACL reconstruction between 2007 and 2022. Ipsilateral and contralateral surgeries were analyzed in both groups. Patient-reported outcomes (Lysholm score, Knee Injury and Osteoarthritis Outcome Score [KOOS], Tegner Activity Scale, and International Knee Documentation Committee [IKDC] scores) were compared between the two groups. The impact of sports activity level and sex on revision rates was examined. Statistical tests, including two-sample Z tests and two-sample t-tests, were used for analysis. Secondary surgeries were defined as additional procedures after ACL reconstruction, microfracture, hardware removal, and arthrolysis.

RESULTS: Group 1 (average age: 15.2 years) included 70 patients with a follow-up of 6.9 years, and Group 2 (average age: 30.8 years) included 87 patients with a follow-up of 3.66 years. A significant age difference was found (p<0.001). Group 1 had higher rates of contralateral ACL surgeries (18.3% vs. 1.1%, p=0.03), meniscus surgeries (26% vs. 4.6%, p=0.003), and secondary surgeries (44% vs. 21%, p=0.01) compared to Group 2. Female athletes under 16 years had a significantly higher rate of contralateral ACL reconstruction (92% vs. 69%, p=0.020). In Group 1, the KOOS Pain score was significantly higher (95.6 vs. 94.0, p=0.033), but the Symptoms score was significantly lower (75.6 vs. 85.0, p<0.005).

CONCLUSION: Patients under 16 years undergoing ACL reconstruction had higher rates of both contralateral and ipsilateral ACL surgeries, as well as secondary surgeries, compared to older patients. Female adolescents had a significantly higher incidence of contralateral ACL reconstruction.

PMID:40528219 | DOI:10.1186/s13018-025-05935-5

Ital J Pediatr. 2025 Jun 17;51(1):192. doi: 10.1186/s13052-025-01977-x.

ABSTRACT

BACKGROUND: The shortage of Pediatric Intensive Care Unit (PICU) beds among some Italian regions is a major concern, especially during epidemics. During respiratory syncytial virus (RSV) bronchiolitis peak, Neonatal Intensive Care Units (NICU) often admit infants and toddlers requiring advanced respiratory support. We conducted a survey to quantify children hospitalized for RSV bronchiolitis in NICU in 2021 and to examine the adherence to treatment guidelines.

METHODS: Early Childhood Intensive Care Working Group of the Italian Society of Neonatology (SIN) conducted a survey distributed to SIN Network NICUs. The modified Delphi method was used to prepare the survey; duplicate responses were excluded. Analysis evaluated percentages.

RESULTS: Response rate was 67% (78/117 NICUs). Geographic distribution of responding centers was: 51% Southern-Islands, 38% North, 11% Center; 50% were Territorial Hospitals, 20% University Hospitals. Of respondents, 55% have 5-10 NICU beds; 70% routinely admit children > 44 weeks postconceptional age and > 28 days old, with a rate of < 10 toddlers/year in 50% of cases, 10-20 toddlers/year in 25% of cases and > 20 toddlers/year in 15%. In 2021, 40% of NICUs admitted < 10 bronchiolitis cases, 29% 11-20 cases. RSV was the leading cause of bronchiolitis. Reasons for NICU admission were respiratory distress syndrome (92%), feeding difficulties (58%), comorbidities (20%). High-flow oxygen (87%) and non-invasive ventilation (60%) were common respiratory supports provided; 10% of patients needed invasive ventilation. Treatment included inhaled steroids (46%), bronchodilators/systemic steroids (32%), antibiotics (40%); 60% of centers did not use sedation during NIV; 30% used midazolam, 13% dexmedetomidine, < 10% fentanyl.

CONCLUSIONS: Our survey highlights that during the RSV epidemic, NICUs admitted toddlers to receive advanced respiratory support unavailable in pediatric ICUs. Most of the NICUs admitted fewer than 10 toddlers per year and less than 10 bronchiolitis, posing skill challenges for medical staff. This supports SIN’s proposal to identify some “extended NICUs” in regions with limited PICU beds, to centralize toddlers after an adequate training to gain knowledge/technical skills specific of pediatric critical care. This would help to overcome the PICU beds storage. Adherence to bronchiolitis management guidelines resulted suboptimal, with frequent but unrecommended use of inhaled steroids, bronchodilators, and antibiotics.

PMID:40528201 | DOI:10.1186/s13052-025-01977-x

Crit Care. 2025 Jun 17;29(1):248. doi: 10.1186/s13054-025-05462-z.

ABSTRACT

Survivors of intensive care unit (ICU) are increasingly numerous because of better hospital care. However, several consequences of an ICU stay, known as post-intensive care syndrome, worsen long-term prognoses. A predominant feature in survivors is reduced muscle strength, mass, and physical function. This leads to lower exercise capacity, long-lasting physical disability, higher mortality risk, and subsequent health costs. While ICU-acquired muscle weakness has been extensively studied these past decades, underlying mechanisms of post-ICU muscle weakness remain poorly understood, and there is still no evidence-based treatment for improving long-term physical outcomes. One hypothesis, among others, could be that the pathophysiology is dynamic over time, differing between the acute ICU and post-ICU recovery periods. This narrative review aims to address the clinical, physiological and biological determinants of persistent muscle dysfunction in ICU survivors, with particular attention to the molecular, cellular and systemic mechanisms involved. Specifically, pre-ICU health factors such as obesity and sarcopenia, ICU-related complications and treatments, and post-ICU management all influence recovery. Dysfunctions in the neuroendocrine, vascular, neurological, and muscle systems contribute as physiological determinants of the muscle weakness. Complex and multifaceted biological mechanisms drive the post-ICU muscle dysfunction with mitochondrial and autophagy dysfunction, epigenetic modifications, cellular senescence, muscle inflammation with altered cell-cell communication, including dysfunction of immune cells, stem cell exhaustion and extracellular matrix remodelling. The review also sheds light on new and innovative therapeutic approaches and discusses future research directions. Emphasis is placed on the potential for multi-approach treatments that integrate nutritional, physical, and biological interventions. Addressing these aspects in a holistic and dynamic manner, from ICU to post-ICU phases, may provide avenues for mitigating the long-term burden of muscle weakness and physical disability in ICU survivors.

PMID:40528196 | DOI:10.1186/s13054-025-05462-z

Int J Equity Health. 2025 Jun 17;24(1):178. doi: 10.1186/s12939-025-02470-x.

ABSTRACT

BACKGROUND: Despite progress in maternal health coverage in Mexico, inequities persist, particularly in postnatal care. The COVID-19 pandemic further widened these gaps, disproportionately affecting women with similar health needs but different socioeconomic conditions. This study assesses trends in maternal healthcare coverage and inequity across nine stages of antenatal, delivery, and postnatal care, comparing pre- and post-pandemic periods. By examining horizontal inequity, we identify critical gaps and policy implications to enhance equitable maternal healthcare access.

METHODS: We conducted a population-based, pooled cross-sectional and retrospective analysis for the last three decades, using data from the five waves (1997, 2009, 2014, 2018, and 2023) of the Mexican National Survey of Demographic Dynamics (ENADID). Our study included 123,197 Mexican women aged 12-54 with recent live births, representing a population of 38.5 million. We estimated coverage for antenatal and postnatal care stages. We used multiple regression models to assess factors influencing the likelihood of receiving comprehensive antenatal care, skilled delivery care and postpartum care interventions, both pre-and post-COVID-19. We estimated horizontal inequity using concentration index and decomposition analysis to highlight disparities among women with similar needs and examine how these disparities have changed due to COVID-19 across nine antenatal, delivery, and postnatal care stages.

FINDINGS: Full antenatal and postnatal health care in Mexico was inadequate and inequitable. Only 73% of pregnant women received timely antenatal care and 88.3% received frequent care, despite 97.9% claiming to have received some care. Inadequate care was linked to lower education, labour market participation, low socioeconomic status, higher parity, and rural residency. The most inequitable aspects are access to skilled and institutional health care and timely post-partum care. The dismantling of a public health insurance system and focused strategies that incentivized the use of maternal health services during the pre-COVID period (January 2019 to March 2020) led to significant health coverage losses, exacerbating horizontal inequity in these areas. Although high equity was achieved in comprehensive antenatal healthcare from 2009 to 2023, since COVID, inequity has increased, particularly in antenatal indicators such as receiving four or more antenatal check-ups and check-ups in the first trimester. The pandemic intensified these inequities, and the values of these indicators have not returned to pre-pandemic levels, underscoring the seriousness of the situation.

CONCLUSIONS: Despite efforts to improve maternal care, comprehensive antenatal services reach only 61.8% of women in Mexico. This stresses not only the need for targeted policies to enhance antenatal, delivery, and postnatal coverage at critical stages of care, but also the need to continue strengthening strategies that have rendered good results, and not to eliminate them simply for political-ideological reasons. It is imperative to prioritize reducing existing inequalities within the population, as horizontal inequity reveals significant barriers preventing equitable access to maternal health services among women with similar needs. The most pronounced disparities exist in timely healthcare access, skilled deliveries, and institutional postnatal care, where systemic issues and financial constraints are particularly impactful. Addressing these inequities is essential not only to improve overall maternal health outcomes but also to ensure that all women can benefit from the full spectrum of maternal care, particularly in situations of health crisis, such as pandemics.

PMID:40528188 | DOI:10.1186/s12939-025-02470-x

Med Decis Making. 2025 Jun 17:272989X251342459. doi: 10.1177/0272989X251342459. Online ahead of print.

ABSTRACT

BackgroundEconomic evaluations for life-extending treatments frequently require clinical trial data to be extrapolated beyond the trial duration to estimate changes in life expectancy. Conventional survival models often display hazard profiles that do not rise as expected in an aging population and require the incorporation of external data to ensure plausibility. Relative survival (RS) models can enable the incorporation of external data at model fitting. A comparison was performed between RS and “standard” all-cause survival (ACS) in modeling outcomes from the tafamidis for the treatment of transthyretin amyloid cardiomyopathy (ATTR-ACT) trial.MethodsPatient-level data from the 30-mo ATTR-ACT trial were used to develop survival models based on parametric ACS and RS models. The latter was composed of an expected hazard and an independent excess hazard. Models were selected according to statistical goodness of fit and clinical plausibility, with extrapolation up to 72 mo validated against ATTR-ACT long-term extension (LTE) data.ResultsInformation criteria were too similar to discriminate between RS or ACS models. Several ACS models were affected by capping with general population mortality rates and considered implausible. Selected RS models matched the empirical hazard function, could not fall below general population hazards, and predicted well compared with the LTE data. The preferred RS model predicted the restricted mean survival (RMST) to 72 mo of 51.0 mo (95% confidence interval [CI]: 46.1, 55.3); this compared favorably to the LTE RMST of 50.9 mo (95% CI: 47.7, 53.9).DiscussionRS models can improve the accuracy for modeling populations with high background mortality rates (e.g., the ATTR-CM trial). RS modeling enforces a plausible long-term hazard profile, enables flexibility in medium-term hazard profiles, and increases the robustness of medical decision making.HighlightsTo inform survival extrapolations for health technology assessment, a relative survival model incorporating external data per the recommendations of the National Institute for Health and Care Excellence (NICE) Decision Support Unit was used in support of the NICE evaluation of tafamidis for treatment of transthyretin amyloid cardiomyopathy (ATTR-CM).Relative survival modeling allowed selection of a broader range of hazard profiles compared with all-cause survival modeling by ensuring plausible long-term predictions.Predictions from plausible relative survival models of overall survival in patients with ATTR-CM, extrapolated from the ATTR-ACT trial, validated very well to outcomes after a doubling of follow-up and demonstrated improved precision and accuracy versus parametric all-cause survival models.

PMID:40528187 | DOI:10.1177/0272989X251342459

BMC Nurs. 2025 Jun 17;24(1):654. doi: 10.1186/s12912-025-03257-9.

ABSTRACT

INTRODUCTION: Prematurity is a significant global health challenge. Premature infants frequently need invasive mechanical ventilation until their lungs are fully developed. Due to the possible complications of ventilation, nurses in the neonatal intensive care unit (NICU) must deliver specialized care to achieve the best outcomes for these infants.

OBJECTIVE: This study aimed to explore the effectiveness of nurses’ training in mechanical ventilation weaning on neonatal outcomes.

METHOD: A quasi-experimental non-equivalent group design was used with purposive sampling of 70 nurses and 64 newborn infants on invasive mechanical ventilation. The infants were divided into two groups: 32 weaned by trained nurses (study group) and 32 weaned by standard methods (control group). Data was collected using a structured questionnaire about the nurses and neonates. A well-designed training program, including theoretical and practical components, was conducted for the nurses to ensure proper weaning of neonates from mechanical ventilation.

RESULTS: The study group demonstrated a significant reduction in the use of surfactant replacement therapy post-extubation compared to the control group (p = 0.003). Additionally, infants in the study group experienced a statistically significant decrease in NICU hospitalization duration, total weaning time, and total ventilation period compared to the control group (p = 0.003, 0.0001, and 0.0001, respectively). Complications were markedly lower in the study group, with two-thirds of infants experiencing no complications, compared to 15.6% in the control group (p = 0.001). Moreover, re-intubation rates were significantly reduced in the study group compared to the control group (p = 0.1026).

CONCLUSION: These results highlight the effectiveness of the intervention in improving clinical outcomes for neonates, including reduced treatment needs, shorter hospital stays, and fewer complications.

CLINICAL TRIAL NUMBER: Not applicable.

PMID:40528182 | DOI:10.1186/s12912-025-03257-9

Scand J Trauma Resusc Emerg Med. 2025 Jun 17;33(1):107. doi: 10.1186/s13049-025-01418-y.

ABSTRACT

BACKGROUND: Healthcare systems are increasingly shifting toward specialization and centralization. As a result, distances are growing between emergency patients and suitable emergency hospitals, as well as in between hospitals for interhospital transfers. Helicopter Emergency Medical Services (HEMS) are essential in maintaining equitable access to emergency care, particularly in rural regions. However, the availability and quality of HEMS landing infrastructure at hospitals remains largely unexamined. This study provides the first nationwide integrated mapping and analysis of emergency care hospital and HEMS landing facility distribution.

METHODS: We conducted a nationwide cross-sectional analysis of all German hospitals classified under the Emergency Care Level system (ECL I-III). Using data from hospital quality reports, government registries, and satellite imagery, we assessed the availability and type of HEMS landing facilities, categorized as certified helipads or Public Interest Sites (PIS). The study aimed to map and characterize the emergency care hospital and HEMS infrastructure, identify associated hospital and regional factors, and assess spatial access and data completeness through targeted analyses.

RESULTS: Of 1,037 emergency care hospitals, 69.6% have a designated landing facility, with 44.0% of these featuring a certified helipad and 56.0% relying on PIS. A substantial proportion of hospitals (30.4%) lack any HEMS landing facility, especially in urban areas. Certified helipads are more prevalent at higher-tier emergency hospitals (ECL II and III) but no landing facility is available at 18.3% of these facilities, particularly in metropolitan regions. Hospitals in rural areas are more likely to have a HEMS landing facility.

CONCLUSIONS: Despite the crucial role of HEMS in emergency medical care, nearly one-third of Germany’s emergency care hospitals lack designated landing facilities, with PIS still outnumbering certified helipads. This reflects structural and regulatory shortcomings that may compromise timely access to specialized care. Enhancing national oversight, modernizing infrastructure, and adopting harmonized European standards are key measures to ensure reliable aeromedical access – and to improve patient outcomes across borders.

PMID:40528175 | DOI:10.1186/s13049-025-01418-y

Crit Care. 2025 Jun 17;29(1):247. doi: 10.1186/s13054-025-05461-0.

ABSTRACT

BACKGROUND: The routine use of sedation and analgesia during post-cardiac arrest care and its association with clinical outcomes remain unclear. This study aimed to describe the use of sedatives and analgesics in post-cardiac arrest care, and evaluate associations with good functional outcome, survival, clinical seizures, and late awakening.

METHODS: This was a post hoc analysis of the TTM2-trial, which randomized 1900 out-of-hospital cardiac arrest patients to either normothermia or hypothermia. In both groups, deep sedation (Richmond Agitation and Sedation Scale ≤ -4) was mandatory during the 40-h intervention. Cumulative doses of sedatives and analgesic drugs were recorded within the first 72 h from randomization. Outcomes were functional outcome (modified Rankin Scale) and survival status at 6 months, occurrence of clinical seizures during the intensive care stay, and late awakening (Full outline of unresponsiveness motor score of four 96 h after randomization). Cumulative propofol doses were divided into quartiles (Q1-Q4). Logistic regression models were used to assess associations between sedative doses and functional outcome and survival, clinical seizures, and late awakening, adjusting for the severity of illness and other clinical factors influencing sedation.

RESULTS: A total of 1861 patients were analyzed. In a multivariable logistic regression model, higher propofol doses (Q3, 100.7-153.6 mg/kg) were associated with good functional outcome (OR 1.62, 95%CI 1.12-2.34) and (Q2 and Q3, 43.9-153.6 mg/kg) with survival (OR 1.49, 95%CI 1.05-2.12 and OR 1.84, 95%CI 1.27-2.65, respectively). Receiving fentanyl and remifentanil were associated with good functional outcome (OR 1.69, 95%CI 1.27-2.26 and OR 1.50, 95%CI 1.11-2.02) and survival (OR 1.80, 95%CI 1.35-2.40 and OR 1.56, 95%CI 1.16-2.10). Receiving fentanyl (OR 0.64, 95%CI 0.48-0.86) and higher propofol doses (Q2-4 (43.9-669.4 mg/kg) were associated with the occurrence of clinical seizures. The highest quartile of propofol dose (153.7-669.4 mg/kg, OR 3.19, 95%CI 1.91-5.42) was associated with late awakening.

CONCLUSIONS: In this study, higher doses of propofol and the use of remifentanil and fentanyl were associated with good functional outcome and survival, occurrence of clinical seizures, and late awakening.

PMID:40528173 | DOI:10.1186/s13054-025-05461-0

Forensic Sci Int Genet. 2025 Jun 11;79:103316. doi: 10.1016/j.fsigen.2025.103316. Online ahead of print.

ABSTRACT

Over the past decade, numerous assays for forensic age estimation based on the analysis of DNA methylation markers have been developed, demonstrating significant potential for use in criminal investigations. Despite these advancements, only few comprehensive evaluation studies were published. In this study, we present findings of an extensive inter-laboratory evaluation of the VISAGE Enhanced Tool and its associated statistical models for epigenetic age estimation in blood and buccal swabs. Six laboratories conducted reproducibility, concordance, and sensitivity assessments using DNA methylation controls alongside blood and saliva samples to evaluate the tool’s technical performance. Results demonstrated consistent and reliable DNA methylation quantification across all participating laboratories, with the tool maintaining sensitivity even with a DNA input of 5 ng for bisulfite conversion. To evaluate the age estimation models, 160 blood and 100 buccal swab samples were analysed in three laboratories. The models achieved mean absolute errors (MAEs) of 3.95 years for blood and 4.41 years buccal swabs, which represents an increase of ∼0.7 years for both tissues to the results from the original VISAGE testing set. When comparing results of each laboratory with the original VISAGE testing set, significant differences were found only for age estimation results from blood of one laboratory with an underestimation of chronological age observed within the entire range tested at that laboratory. When excluding this laboratory, the MAE decreased to 3.1 years (N = 89). No significant differences among laboratories were found for buccal swabs. Overall, this study confirms that the VISAGE Enhanced Tool performs robust DNA methylation quantification and reliable age prediction, however protocol and model validation within each laboratory is required upon implementation.

PMID:40526988 | DOI:10.1016/j.fsigen.2025.103316

Appl Ergon. 2025 Jun 16;129:104579. doi: 10.1016/j.apergo.2025.104579. Online ahead of print.

ABSTRACT

This study investigated the effects of different magnifications of the Galilean system on the posture of dental students during pre-clinical procedures. Thirty-seven second-year undergraduate dental students participated in this study. Dependent variables included angular deviation from the neutral position of the neck, neck muscle activity, and working distance from the operator’s eyes to the mannequin’s mouth. The independent variable was the magnification of the Galilean system loupes at four levels (naked eye, 2.5×, 3.0 × , and 3.5× magnification). Students performed Class I teeth preparations on the maxillary first molar using a dental mannequin, and postures were recorded on photographs during the procedure. The “Software for Postural Assessment” (version 0.69) analyzed the angular deviation and working distance. Muscle activity was assessed bilaterally using surface electromyography of the descending trapezius and sternocleidomastoid muscles. Descriptive statistical analysis and one-way repeated-measures analysis of variance (rANOVA) was conducted (α = 0.050). As a result, a greater angular deviation of the neck was observed with the naked eye during tooth preparation (p < 0.001). However, different magnifications did not affect the muscle activity (p = 0.050-0.911) or working distance (p = 0.136). It was possible to conclude that, regardless of the magnification, using Galilean loupes reduced angular deviation; however, it did not influence muscle activity or working distance.

PMID:40526987 | DOI:10.1016/j.apergo.2025.104579