Nevin Manimala

JAMA Netw Open. 2026 Mar 2;9(3):e263161. doi: 10.1001/jamanetworkopen.2026.3161.

ABSTRACT

IMPORTANCE: Exploring the relationship between moral distress and occupational burnout is necessary to understand the association between these constructs.

OBJECTIVE: To evaluate moral distress among physicians and US workers, and to explore the association of moral distress with burnout, intent to leave (ITL) current position, and intent to reduce clinical work hours (ITR).

DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional national survey study included physicians from all specialties and a probability-based sample of employed nonphysicians. Participants were aged 29 to 65 years. Data were collected between October 19, 2023, and March 5, 2024. Data were analyzed from June 30 to October 20, 2025.

MAIN OUTCOMES AND MEASURES: Moral distress was measured using the Moral Distress Thermometer (MDT, range 0-10), with a high level of moral distress defined by a score of 4 or higher. Burnout was measured using the complete Maslach Burnout Inventory (MBI). Professional fulfillment was measured using the Stanford Professional Fulfillment Index. ITL and ITR were measured using a standardized item with response options of none, slight, moderate, likely, and definitely.

RESULTS: This survey study included 5741 physicians and 3501 nonphysician US workers. The median (IQR) age of physicians was 53 (44-62), and included 3262 men (58.0%), 2255 women (40.1%), and 107 individuals who responded other (1.9%). The mean (SD) moral distress score for physicians was 3.29 (2.81), with 2243 (39.1%) reporting a high level of moral distress (4 or more considered high). On multivariable analysis, women physicians had higher odds of moral distress (OR, 1.29; 95% CI, 1.12-1.48). Compared with internal medicine subspecialists, emergency medicine physicians (OR, 3.16; 95% CI, 2.27-4.4) and general internal medicine physicians (OR, 1.92; 95% CI, 1.42-2.59) were more likely to report high levels of moral distress. Mean emotional exhaustion and depersonalization scores, as well as the proportion of physicians with burnout, were higher with each 1-point increase in moral distress score. The overall correlation between the emotional exhaustion score and moral distress score was R = 0.55 (P < .001) while the correlation between the depersonalization score and moral distress score was R = 0.50 (P < .001). Additionally, 1068 of 3477 physicians (30.7%) with a moral distress score less than 4 had burnout symptoms compared with 1675 of 2231 physicians (75.1%) with scores of 4 or more (P < .001). The prevalence of ITL and ITR was higher for each 1-point increase in moral distress score. For example, 619 of 3404 physicians (18.2%) with low moral distress reported ITL within 24 months compared with 748 of 2171 (34.5%) among those with high moral distress (P < .001). Compared with other US workers, physicians had markedly higher odds of experiencing moral distress (OR, 4.40; 95% CI, 3.84-5.06).

CONCLUSION AND RELEVANCE: In this survey study, moral distress was common among physicians and experienced at higher rates than the general US working population. Understanding the differences between moral distress and burnout may allow organizations to more effectively implement interventions to address both concerns among clinicians.

PMID:41874502 | DOI:10.1001/jamanetworkopen.2026.3161

Pract Radiat Oncol. 2025 Oct 18:S1879-8500(25)00224-3. doi: 10.1016/j.prro.2025.09.001. Online ahead of print.

ABSTRACT

PURPOSE: The recently published results of the National Surgical Adjuvant Breast and Bowel Project B51 trial suggest that regional nodal irradiation may be safely omitted in patients with cT1-3N1 breast cancer treated with either lumpectomy or mastectomy, and achieve a pathologic complete response (pCR) in the regional nodes. Of note, almost 80% of patients on the trial demonstrated breast pCR. The goal of our study was to compare clinical outcomes between patients with breast pCR versus not.

METHODS AND MATERIALS: We included all patients treated at a single institution between 2010 and 2021 with cT1-3N1 breast cancer (pathologically proven via fine needle aspiration) who completed neoadjuvant chemotherapy and had axillary nodal pCR. Patients could undergo breast-conserving surgery or mastectomy. Univariate and multivariate logistic models were used to identify factors associated with breast pCR. Cox proportional hazard model was used to find independent prognostic variables associated with disease-free survival (DFS).

RESULTS: We identified 124 patients meeting eligibility criteria. Of those, 72 patients (58%) achieved a breast pCR. On multivariate analysis, patients with human epidermal growth factor receptor (HER2)-positive breast cancer were more likely to develop breast pCR than patients with HER2-negative disease (odds ratio = 15.3; CI, 2.9-156.6; P = .001). At a median follow-up of 5 years, our study showed an overall low rate of local recurrence or distant metastasis with 5-year DFS of 92.3%. There was a numerically higher disease recurrence rate in patients without a breast pCR compared to those with a breast pCR, though this difference was not statistically significant (4.2% vs 12%; hazard ratio = 3.41; 95% CI, 0.53-22.1; P = .2).

CONCLUSIONS: Our study showed that of the 124 patients who had pCR in the nodes, only 58% had a pCR in the breast, which is lower than the 80% rate seen in National Surgical Adjuvant Breast and Bowel Project B51. While our study found no significant difference in 5-year DFS between those with breast pCR versus not, given that patients with ER/PR+/HER2- disease are less likely to achieve breast pCR and tend to recur at later timepoints, further research is needed to evaluate the benefit of regional nodal irradiation in patients with a pCR in the axilla without a pCR in the breast.

PMID:41874497 | DOI:10.1016/j.prro.2025.09.001

Ann Emerg Med. 2026 Mar 23:S0196-0644(26)00093-4. doi: 10.1016/j.annemergmed.2026.02.010. Online ahead of print.

ABSTRACT

STUDY OBJECTIVE: Health care researchers, policymakers, and managers have long been concerned with heavy emergency department (ED) use for low-acuity conditions that can be addressed in office-based settings. Clinically, urgent care clinics are a viable substitute. Yet, we know little about how ED use and urgent care use interact, and how their combined or separate use varies across population groups. People may cluster in groups with distinct patterns of combined health care utilization, which we consider a meaningful way to study health care use. We aimed to identify latent classes of adult health care utilization based on observed characteristics.

METHODS: We conducted a latent class analysis to identify distinct classes of health care utilization among adults (18+ years old) using publicly available, de-identified data from the 2022-2023 National Health Interview Survey (N=56,181). The latent class model included 4 indicators and 2 ordinal variables: having the last visit being a wellness visit, having a usual place of care, delaying or foregoing care due to cost, having a hospitalization, urgent care use (0, 1-2 visits, and 3+ visits), and ED use (0, 1, and 2+ visits) in the past year. We compared the fit of 2, 3, and 4-class models using Akaike’s Information Criterion and Bayesian Information Criterion statistics. We then estimated regression models of class probabilities on sociodemographic and health-related characteristics.

RESULTS: A 4-class model had the best model fit. Two classes were distinguished by low health care use: one with barriers to care (“nonusers with access barriers,” the smallest class, 6.8%) and one without (“nonusers without access barriers”; the largest class, 59.7%). The class of “heavy health care users” (15.7%) is characterized by the highest probability of ED use (mean probability of having 1 visit 0.471 and 2+ visits 0.351) and the highest probability of hospitalization (0.515) of all classes, alongside moderate urgent care use (probability of 1+ visits 0.430). The class of “urgent care users” (17.7%) is marked by the highest probability of urgent care use (zero probability of no visit, 0.786 of 1-2 visits and 0.214 of 3+ visits), alongside low probability of ED use and the lowest probability of hospitalizations (<0.01). In adjusted regression analyses, the probability of being in the “nonusers with access barriers” class was substantially higher for the uninsured and the probability of being in the “heavy health care users” class was substantially higher for Medicaid enrollees. The probability of being an “urgent care user” was higher for those with higher educational attainment and private insurance.

CONCLUSION: Our findings suggest that urgent care is either complementary to the ED (in the “heavy health care users” class) or is used alongside low to no use hospital-based care and low to no barriers to care (“urgent care users” class). At the same time, our analysis did not identify a distinct class of ED users, with low to no urgent care use. Our findings can inform health system decisionmaking, especially in areas of health care delivery and improving access.

PMID:41874493 | DOI:10.1016/j.annemergmed.2026.02.010

Echocardiography. 2026 Mar;43(3):e70422. doi: 10.1111/echo.70422.

ABSTRACT

OBJECTIVE: The precise and consistent identification of fetal cardiac structures and functional flows is essential for the early diagnosis of congenital heart defects (CHDs), yet interobserver variability remains a significant challenge in clinical practice. Although fetal cardiac magnetic resonance imaging (MRI) has emerged as a valuable adjunct in selected cases, its routine use remains limited by long acquisition times, motion artifacts, and restricted availability in many centers. This underscores the need to optimize ultrasound-based techniques that can reduce reliance on MRI while still providing comprehensive and reproducible fetal cardiac assessment. This article presents a study investigating the reliability of a layered imaging approach combined with standardized B-mode and color Doppler ultrasound protocols to improve interobserver agreement in image interpretation among experts in fetal echocardiography.

METHODS: A dataset comprising 209 B-mode and 205 color Doppler recordings acquired during midgestational anomaly scans (mean gestational age: 21.2 weeks) was systematically evaluated by five expert supervisors. Interobserver agreement was quantified using the prevalence-adjusted bias-adjusted kappa (PABAK) coefficient. To evaluate consistency across anatomical layers, one-way ANOVA was employed, followed by post hoc analysis where applicable.

RESULTS: Most anatomical structures and functional features were consistently identified across observers, certain structures posed challenges, likely owing to their smaller size, lower visibility, or greater variability in presentation.

CONCLUSION: By integrating structured imaging sequences with advanced statistical methodologies, this study explored the potential of improving diagnostic accuracy and standardization in fetal cardiac assessments, offering insights into the development of more reliable protocols for clinical applications and future research.

PMID:41874471 | DOI:10.1111/echo.70422

J Med Econ. 2026 Dec;29(1):940-956. doi: 10.1080/13696998.2026.2643130. Epub 2026 Mar 24.

ABSTRACT

BACKGROUND: COVID-19 annual vaccination uptake in Spain remains suboptimal. This study aimed to estimate the clinical and economic impact of the 2023/2024 COVID-19 vaccination campaign in individuals aged ≥60 years (scenario A: coverage of 33.14% for ages 60-69, 53.15% for 70-79, and 65.32% for ≥80), and to compare it with a hypothetical scenario (scenario B) where coverage reaches the 75% target set by the Spanish Ministry of Health.

METHODS: A combined Markov-decision tree model adapted to the Spanish context simulated the weekly progression of the target population through six health states over one year. Infected individuals entered a decision tree reflecting different care pathways (outpatient, hospital ward, ICU with/without invasive mechanical ventilation [IMV], or death), each associated with specific health outcomes and direct costs (€2024). Clinical and economic outcomes were compared between scenarios A and B. Sensitivity analyses explored incremental increases in coverage and age-specific impacts. The analysis was conducted from the National Healthcare System (NHS) perspective.

RESULTS: Under scenario A, 378,970 symptomatic infections occurred, leading to 27,611 hospitalizations, 742 ICU admissions (47.3% requiring IMV), and 3,611 deaths. A total of 2,750 quality-adjusted life years (QALYs) were lost, and COVID-19-related care costs reached €240.4 million (85.7% from inpatient care). Scenario B, with 75% coverage, averted -19,409 symptomatic infections, 1,094 hospitalizations, 41 ICU admissions, and 129 deaths, 138 lost QALYs and total cost savings of about €10.5 million. Sensitivity analysis showed how the model is sensitive to sequential increases (10% by 10%) in vaccination rates and highlighted the importance of achieving high vaccination rates, especially in older age groups.

CONCLUSIONS: This analysis reveals the significant impact that increasing annual COVID-19 vaccination coverage among the Spanish population over 60 could have in preventing new infections, reducing severe disease consequences, and generating considerable cost savings for the NHS.

PMID:41874460 | DOI:10.1080/13696998.2026.2643130

United European Gastroenterol J. 2026 Apr;14(3):e70199. doi: 10.1002/ueg2.70199.

ABSTRACT

INTRODUCTION: Resection of intraductal papillary mucinous neoplasm (IPMN) aims to prevent progression to invasive pancreatic cancer. However, the risks of pancreatic surgery and frequent findings of low-grade dysplasia (LGD) raise concerns about overtreatment. This EAHPBA-endorsed multinational study evaluated short- and long-term overall survival (OS) following preventive resection for IPMN (without pre-operative signs of cancer).

METHODS: Adult patients with resected IPMN showing LGD, high grade dysplasia (HGD) or T1-staged invasive carcinoma from 2008-2023 were identified from the OPTIMAL-IPMN database. Estimated OS rates at one, five and 10 years in patients undergoing preventive pancreatic resection were assessed using Kaplan-Meier analyses and predictors for mortality were evaluated using parametric survival regressions.

RESULTS: Among 2275 patients in the OPTIMAL-IPMN database, 1728 (77%) had undergone preventive pancreatic resection for IPMN. Of those were 61% resected without prior surveillance. Final pathology revealed LGD in 63%, HGD in 27% and T1a-c-staged invasive cancer in 10% (7.3% T1a-b, 2.8% T1c). Estimated 1-year OS rate was 97%. Estimated 5-year OS rates (landmark analysis at 1 year) for LGD, HGD, T1a-b, and T1c was 97%, 99%, 96% and 91% respectively. Independent predictors for long-term mortality included age ≥ 75 versus < 75 years (HR 1.97) and T1c versus LGD (HR 8.12).

CONCLUSION: This multinational study confirms excellent survival after preventive IPMN resection but reveals many upfront resections yielding LGD with unknown survival benefit. Future studies should aim to determine which patients can be followed safely with monitoring to avoid unnecessary immediate resection.

PMID:41874453 | DOI:10.1002/ueg2.70199

Int J Pharm Pract. 2026 Mar 24:riag004. doi: 10.1093/ijpp/riag004. Online ahead of print.

ABSTRACT

OBJECTIVES: The healthcare sector is evolving with a growing emphasis on remote services and patient-centred care. Medication Home Delivery (MHD) service has become essential in enhancing accessibility, allowing patients to receive medications at home. This study evaluates the perceptions, practices, challenges, and benefits of the MHD service among community pharmacists in the United Arab Emirates (UAE), providing insights for policy and practice improvements.

METHODS: A cross-sectional survey was conducted among 403 licensed community pharmacists in the UAE. Participants completed a self-administered questionnaire assessing their awareness, perceptions, and experiences with the MHD service. Data analysis included descriptive statistics and logistic regression to identify factors influencing service provision.

KEY FINDINGS: Among respondents, 83.6% offered the MHD service, primarily through online platforms. Main factors influencing service provision included participants’ age, employment status, pharmacy type, and location (P < .05). Pharmacists raised concerns about patient counseling quality, communication, and medication security, highlighting the need for training to improve regulatory adherence. Major challenges included staffing shortages (51.6%), increased workload (36.5%), and limited time for patient counseling (41.2%). Despite these barriers, most pharmacists recognized MHD’s benefits in enhancing pharmacy efficiency (87.2%) and patient convenience (51.3%), particularly for elderly and disabled individuals (86.9%). Those not offering the MHD service cited unclear policies (24.2%) and logistical constraints as primary barriers (24.2%).

CONCLUSIONS: This study underscores both the opportunities and operational challenges of the MHD service in the UAE community pharmacies. Optimizing the service requires policy refinements, improved logistical frameworks, and targeted training programs to enhance service delivery, regulatory compliance, and patient care outcomes.

PMID:41874442 | DOI:10.1093/ijpp/riag004

Mol Omics. 2026 Mar 24:aaiag014. doi: 10.1093/molecular-omics/aaiag014. Online ahead of print.

ABSTRACT

Metaproteomics is an effective tool for characterizing the functional profiles of microbial communities by directly measuring protein expression. However, prospective power analysis and sample-size estimation are often overlooked at the study design stage in metaproteomics, which can result in underpowered experiments and reduced ability to detect biologically meaningful effects. In this study, we present a practical, end-to-end workflow for conducting power analysis prior to data collection. We focus on three common experimental designs: between-group comparisons, parallelized perturbation experiments, and beta diversity analyses. To tailored these experimental designs, we consider three major statistical approaches for power estimation: parametric tests (e.g., t-test, ANOVA), non-parametric tests (e.g., Wilcoxon rank-sum, Kruskal-Wallis), and distance-based multivariate methods (e.g., PERMANOVA using Bray-Curtis). By presenting detailed case studies, we provide practical guidance on how to calculate effect sizes, generate simulated datasets, and estimate statistical power across varying sample sizes. We also supply corresponding visualizations for each scenario to support sample-size determination and power assessment. This framework is intended to help researchers optimize sample size, improve experimental efficiency, and reduce costs, thereby enabling more reliable and interpretable biological insights from metaproteomic studies.

PMID:41874428 | DOI:10.1093/molecular-omics/aaiag014

United European Gastroenterol J. 2026 Apr;14(3):e70204. doi: 10.1002/ueg2.70204.

ABSTRACT

BACKGROUND: The low fermentable oligo-, di-, monosaccharide and polyol (FODMAP) diet (LFD) effectively manages irritable bowel syndrome (IBS), but predictors of treatment response remain unknown.

OBJECTIVE: This study investigated whether psychological factors predict symptom improvement and quality of life (QoL) outcomes following a LFD intervention.

METHODS: Adults with Rome IV-defined IBS underwent a three-phase LFD over 6 months. Primary outcomes were IBS symptom severity and QoL. Validated questionnaires assessed depressive, gastrointestinal-specific anxiety (GSA), and somatic symptoms, illness perceptions, and treatment expectations. Latent class growth analysis (LCGA) and cross-lagged panel models (CLPM) were used to identify symptom trajectories and examine directional relationships between psychological factors and outcomes, respectively.

RESULTS: 112 participants (89% female, median age 30 ± 17 years) completed the study. LCGA identified distinct IBS symptom severity and QoL trajectories during the LFD. Higher baseline treatment credibility and expectancy predicted favourable symptom improvements but were unrelated to membership in the QoL trajectory. Elevated GSA, psychological distress (depression, anxiety, stress), and negative illness perceptions increased the likelihood of poorer outcomes. CLPM revealed that lower GSA and higher personal control preceded subsequent symptom reductions. Higher treatment expectancy predicted improved QoL and symptom outcomes over time, while QoL improvements reduced stress and GSA.

CONCLUSION: Lower baseline GSA anxiety and higher treatment expectations consistently predict better response to all phases of the LFD. These findings will help clinicians identify optimal candidates for dietary intervention versus alternative treatments.

PMID:41874426 | DOI:10.1002/ueg2.70204

J Spinal Cord Med. 2026 Mar 24:1-9. doi: 10.1080/10790268.2025.2598981. Online ahead of print.

ABSTRACT

BACKGROUND: Infiltrations of the spine can be used to treat nociceptive or neuropathic pain. There is little data in the literature on the use of spinal injections in patients with paraplegia.

OBJECTIVE: The aim of this study is to determine whether patients with spinal cord injury experienced improvement in pain and spasticity following spinal injection.

METHODS: 19 (9 female, 10 male) patients (5 patients AIS A, 5 patients AIS C, 9 patients AIS D), including 9 tetraplegic and 10 paraplegic patients, with 22 injection techniques and a follow-up of 4.2 months (1-12 months) were retrospectively examined in our spinal cord injury Center in 2022 and 2023. The pain intensity on the NRS (Numerical Rating Scale), the MAS (Modified Ashworth Scale) for the graduation of muscle tone and the Spinal Cord Independence Measurement (SCIM) were assessed before infiltration and as part of the follow-up examination.

RESULTS: Image intensifier-assisted facet and sacroiliac joint infiltrations were performed in 12 patients, CT-guided nerve root infiltrations and epidural injections in 10 patients with corresponding symptoms and image morphological correlate without complications. In all patients, a statistically significant reduction in pain on the NRS could be achieved (4.05 ± 1.84; p < 0.0001). A trend towards improvement was documented in the analysis of the MAS (0.14 ± 0.35; p = 0.08), whereas a significant improvement was statistically detected in the analysis of the SCIM (-15.59 ± 18.23; p = 0.0006).

CONCLUSION: Our study represents the first retrospective exploratory analysis (phase I-style feasibility study) after spinal injection in patients with spinal cord injury. The primary results in terms of pain intensity, muscle tone and independence are promising and, in our view, represent a further therapeutic approach in addition to pharmacological and non-pharmacological therapy options. However, further investigations are necessary for this.

PMID:41874322 | DOI:10.1080/10790268.2025.2598981