Nevin Manimala

JAMA Netw Open. 2026 Jul 1;9(7):e2626522. doi: 10.1001/jamanetworkopen.2026.26522.

ABSTRACT

IMPORTANCE: Remote patient monitoring (RPM), including self-measured blood pressure monitoring with clinician review and telehealth-supported feedback, can support hypertension management. However, RPM use and related care continuity after switching from Medicare fee-for-service (FFS) to Medicare Advantage (MA) remain unclear.

OBJECTIVE: To compare RPM adoption, clinician continuity, and hypertension-related acute care utilization among beneficiaries who remained in Medicare FFS vs switched to MA plans, categorized as value-based contract (VBC) proxy or non-VBC.

DESIGN, SETTING, AND PARTICIPANTS: This cohort study with an observational difference-in-differences design with propensity score matching used data from 2016 to 2022 Medicare enrollment, FFS claims, and MA encounter data. Beneficiaries were aged 65 years or older with prevalent diagnosed hypertension in 2018 and continuous enrollment in Parts A and B in 2018. Treated groups switched from FFS to MA in January 2019 and remained enrolled through 2022; comparators remained in FFS. Follow-up extended from January 1, 2019, through December 31, 2022. Data analysis was conducted from April to July 2025.

EXPOSURE: Switching from Medicare FFS to MA-VBC proxy or MA non-VBC in 2019.

MAIN OUTCOMES AND MEASURES: The primary outcome was annual RPM adoption during hypertension-related visits; secondary outcomes included clinician loss without replacement, clinician switching or substitution, and hypertension-related emergency department (ED) visits and hospitalizations.

RESULTS: Matched samples included 281 620 beneficiaries, with 46 833 MA-VBC proxy plan switchers and 46 833 FFS comparators (27 920 [59.6%] aged 71 years or older and 27 685 female [59.1%] in each group) and 93 977 MA non-VBC switchers and 93 977 FFS comparators (67 188 [71.5%] aged 71 years or older; 53 122 female [56.5%] in each group). Common comorbidities included diabetes, chronic kidney disease, and heart failure. Switching to MA was associated with lower RPM adoption in 2022 (MA-VBC proxy: odds ratio [OR], 0.55; 95% CI, 0.42-0.72; -0.63 percentage points; non-VBC: OR, 0.73; 95% CI, 0.54-0.99; -0.52 percentage points), greater clinician loss without replacement (MA-VBC proxy: OR, 1.27; 95% CI, 1.23-1.32; 3.41 percentage points; MA non-VBC: OR, 1.09; 95% CI, 1.06-1.12; 0.83 percentage points), and higher hypertension-related hospitalizations (MA-VBC proxy: OR, 1.75; 95% CI, 1.48-2.06; MA non-VBC: OR, 1.94; 95% CI 1.71-2.19; 1.56 percentage points in both comparisons). Event-study analyses showed postswitch divergence through 2022.

CONCLUSIONS AND RELEVANCE: In this cohort study of older Medicare beneficiaries with hypertension, switching from FFS to MA was associated with lower RPM adoption, greater clinician discontinuity, and higher hypertension-related acute care use. These findings suggest that continuity safeguards and clearer payment or quality incentives during MA transitions may support remote monitoring and clinician follow-up for hypertension.

PMID:42536372 | DOI:10.1001/jamanetworkopen.2026.26522

JAMA Netw Open. 2026 Jul 1;9(7):e2626538. doi: 10.1001/jamanetworkopen.2026.26538.

ABSTRACT

IMPORTANCE: Perspectives of families from historically marginalized groups regarding pediatric oncology clinical trial participation are not well-represented in the literature.

OBJECTIVE: To describe clinician- and parent-perceived facilitators and barriers to clinical trial participation.

DESIGN, SETTING, AND PARTICIPANTS: This single-center cross-sectional study with an explanatory sequential mixed-methods design enrolled parents of Black and Hispanic children with cancer as well as pediatric oncology clinicians from a large pediatric cancer center in Boston, Massachusetts. Parent participants completed single-time point surveys, and a subset, purposively sampled based on self-identified race and ethnicity, language, and household material hardship (HMH; ie, food, housing, transportation, or utility insecurity), completed semistructured interviews from September to December 2021. Clinicians completed semistructured interviews from February to March 2022. Data were analyzed from April 2022 to October 2025.

MAIN OUTCOMES AND MEASURES: Key factors influencing clinical trial participation in pediatric oncology among parents from historically marginalized groups. Quantitative data were summarized descriptively. Interview transcripts were analyzed using thematic analysis and integrated along key domains.

RESULTS: A total of 60 parents completed the questionnaire; self-identified race and ethnicity included 5 Hispanic Black (8%), 10 Hispanic White (17%), 21 Hispanic other (35%), 21 non-Hispanic Black (35%), and 3 non-Hispanic White (5%) parents; most were mothers (51 [85%]). Twenty parents participated in interviews. Fifteen clinicians (10 [67%] female participants; 10 [67%] with ≥10 years caring for children with cancer) were interviewed, including 12 (80%) attendings and 3 (20%) advanced practice practitioners; most identified as non-Hispanic White (14 [93%]). Most families experienced HMH (44 [73%]) and reported high trust in their oncology team (mean [SD] score, 4.63 [0.65] of 5.00). Qualitatively, parents and clinicians aligned in identifying altruism and trustworthiness as facilitators to trial participation, while the informed consent discussion, non-English language preference, trial materials, and study requirements were participation barriers. Unlike clinicians, parents did not identify HMH or the experimental nature of trials as significant barriers to participation. Parents identified the desire for representation as a facilitator to participation, and clinicians identified gatekeeping as a barrier.

CONCLUSIONS AND RELEVANCE: In this cross-sectional study of pediatric oncology families from historically marginalized groups and clinicians, clinician- and parent-perceived barriers identified opportunities to increase equitable trial participation. Next steps include standardization of trial eligibility screening and systematic HMH screening and support to reduce gatekeeping.

PMID:42536371 | DOI:10.1001/jamanetworkopen.2026.26538

JAMA Netw Open. 2026 Jul 1;9(7):e2626547. doi: 10.1001/jamanetworkopen.2026.26547.

ABSTRACT

IMPORTANCE: Endotracheal aspirate culture (EAC) practices for evaluation of ventilator-associated infections (VAI) vary widely across pediatric hospitals, and overuse can contribute to overdiagnosis and overtreatment for VAI. Diagnostic stewardship strategies to optimize EAC testing practices may reduce overtesting and unnecessary antibiotic treatment.

OBJECTIVE: To evaluate the association of diagnostic stewardship of EACs using clinical decision support with culture rates, antibiotic use, and patient outcomes across a multicenter collaborative of pediatric intensive care units (PICUs).

DESIGN, SETTING, AND PARTICIPANTS: This was a multicenter cohort study with a pre-post study design among the BrighT STAR (Testing Stewardship for Antibiotic Reduction) Quality Improvement (QI) Collaborative involving PICUs across the US between 2019 and 2023. Data were collected from the participating sites and from the Children’s Hospital Association Pediatric Health Information System and were analyzed from August to December 2025.

EXPOSURE: Participating PICUs conducted local QI programs focused on optimizing EAC practices, facilitated by the BrighT STAR collaborative.

MAIN OUTCOMES AND MEASURES: The primary outcome was the monthly rate of EACs per 100 ventilator-days. Secondary outcomes included rates of antibiotic initiations and antibiotic days of therapy, bronchoalveolar lavage cultures, readmissions, length of stay, ventilation duration, ventilation-free days, sepsis, and septic shock. Analysis included adjustment for seasonality.

RESULTS: Across 15 sites (median [IQR] unit size, 30 [25-38] beds), the study captured 106 967 ventilator-days preimplementation and 92 167 ventilator-days postimplementation. Comparing 24 months in the preimplementation period with the 18 months in the postimplementation period, the mean monthly EAC rate declined by 16% from a preimplementation to postimplementation rate of 7.80 to 6.55 cultures per 100 ventilator-days (relative rate [RR], 0.84; 95% CI, 0.78-0.90). The rate of antibiotic initiations remained stable (RR, 0.98; 95% CI, 0.89-1.08), as well as the antibiotic days of therapy rate (RR, 1.03; 95% CI, 0.95-1.11). There were no significant changes in the rates of bronchoalveolar lavage cultures, PICU length of stay, PICU or hospital readmissions, sepsis, septic shock, ventilation duration, or ventilator-free days.

CONCLUSIONS AND RELEVANCE: In this multicenter cohort study, diagnostic stewardship of EACs using clinical decision support led by multidisciplinary teams was associated with reduced EAC use in the PICU without safety concerns. Future work will determine optimal implementation strategies, assess sustainability and the cost impact of EAC stewardship.

PMID:42536370 | DOI:10.1001/jamanetworkopen.2026.26547

JAMA Netw Open. 2026 Jul 1;9(7):e2626634. doi: 10.1001/jamanetworkopen.2026.26634.

ABSTRACT

IMPORTANCE: Previous research has shown neighborhood environmental interventions can improve health and safety for residents. It is unknown whether these interventions impact opioid overdose outcomes.

OBJECTIVE: To evaluate the association of neighborhood environmental interventions with opioid overdose rates.

DESIGN, SETTING, AND PARTICIPANTS: This quasi-experimental nonrandomized trial used a continuous treatment difference-in-differences design and was conducted in a single neighborhood of Philadelphia, Pennsylvania, between January 1, 2019, and December 31, 2021. The quasi-experimental design used nonrandomized comparator groups to evaluate the associations of neighborhood environmental interventions with opioid overdose rates since randomization was not possible. Data analysis took place between May 2022 and February 2025.

INTERVENTIONS: Community trash pickups, vacant lot cleanups, and abandoned house remediation.

MAIN OUTCOMES AND MEASURES: Outcomes of interest were nonfatal and fatal opioid overdoses.

RESULTS: Of 1667 individual blocks (median household income, $37 821) included in the study geography, 622 blocks (37.3%) received at least 1 intervention during the study period. Among 59 590 residents in the study area, there were 1179 Asian residents (2.0%), 9951 Black residents (16.7%), 23 261 White residents (39.0%), 5016 residents (8.4%) who identified as 2 or more races, and 19 903 residents (33.4%) who identified as another race; 30 286 residents (50.8%) were Hispanic or Latinx. A total of 763 community trash pickups, 483 abandoned house remediations, and 855 vacant lot cleanups were included in analysis. In aggregate, the interventions were associated with a significant reduction in fatal opioid overdoses (change, -6.6%; 95% CI, -10.5% to -2.4%), with no measurable association for nonfatal opioid overdoses (change, -0.0%; 95% CI, -3.4% to 3.5%). Abandoned house remediation was associated with a significant reduction in both fatal (change, -17.6%; 95% CI, -26.2% to -7.9%) and nonfatal (change, -11.5%; 95% CI, -19.0% to -3.3%) opioid overdoses. Community trash pickup was not associated with rates of fatal or nonfatal overdoses. Vacant lot cleanup was not associated with rates of fatal overdoses but was associated with a significant increase in nonfatal overdoses (change, 11.7%; 95% CI, 4.0% to 20.0%). No significant displacement associations were found in other locations.

CONCLUSIONS AND RELEVANCE: In this study of the association of neighborhood environmental interventions with opioid overdose rates, interventions analyzed in aggregate were associated with reduced fatal opioid overdoses outcomes, with no association with nonfatal outcomes. Abandoned house remediation was significantly associated with reduced fatal and nonfatal opioid overdose rates and should be considered along with other essential interventions that provide treatment and harm reduction to individuals with substance use disorder.

PMID:42536369 | DOI:10.1001/jamanetworkopen.2026.26634

Biometrics. 2026 Jul 1;82(3):ujag122. doi: 10.1093/biomtc/ujag122.

ABSTRACT

In clinical trials, a treatment rarely benefits every patient, underscoring the need to identify subgroups that are more likely to respond. Traditional subgroup analysis approaches, including finite mixture and threshold models, often rely on stringent distributional assumptions and prespecified subgroup structures that may be unrealistic in practice. Moreover, the resulting subgroups can be difficult to interpret and may not generalize well to new patients. To address these challenges, we propose a new least-squares regression framework that accommodates flexible subgroup structure in heterogeneous data. Our model is distribution-free and allows subgroup membership to depend on covariates, while permitting both the number and the organization of coefficient groups to vary across covariates. Building on regularization, we develop a computationally efficient procedure to detect subgroup structure in linear regression coefficients and then use a support vector machine to recover the corresponding partitions, enabling subgroup membership prediction for future individuals. Relative to pairwise fused regularization, our approach substantially reduces computational complexity. We also establish theoretical guarantees for estimation of group-specific parameters and recovery of the underlying partitions. Simulation studies and a real-data application illustrate the practical effectiveness of the proposed method.

PMID:42536360 | DOI:10.1093/biomtc/ujag122

Cancer Epidemiol Biomarkers Prev. 2026 Jul 31. doi: 10.1158/1055-9965.EPI-26-0300. Online ahead of print.

ABSTRACT

BACKGROUND: It is believed that contact of the urothelial lining to carcinogens induces mutations that lead to cancer. Nocturia, waking up at night to urinate, may void carcinogens and reduce risk of bladder cancer.

METHODS: The Cancer Prevention Study-II Nutrition Cohort is a prospective study of cancer incidence that enrolled participants in 1992 with biennial follow-up beginning in 1997. Cases were ascertained through state cancer registry, medical record verification, or death certificate. Cox models were used to calculate hazard ratios(HR) and 95% confidence intervals(95%CI) for the association between nocturia and primary incident bladder cancer.

RESULTS: Among 49,767 males, 2,655 reported being current smokers in 1997 (30,559 former smokers). There were 1,207 bladder cancers over 210-million person-years of follow-up. Adjusting for demographic and health factors, nocturia once/night was associated with 46% decreased risk of bladder cancer among smokers(HR once/night 0.54, 95%CI 0.30, 0.95; HR 2+/night 0.90, 95%CI 0.52, 1.57). We observed no association among non-smokers(HR once/night 1.10, 95%CI 0.72, 1.69; HR 2+/night 1.17, 95%CI 0.75, 1.81) or former smokers(HR once/night 1.17, 95%CI 0.92, 1.49; HR 2+/night 1.12, 95%CI 0.87, 1.43). Our main findings were no longer statistically significant in 2-year(HR 0.58, 95%CI 0.31, 1.09) and 5-year lag models(HR 0.80, 95%CI 0.32, 1.99).

CONCLUSIONS: Only nocturia once per night was associated with lower risk of bladder cancer in current smokers; however, associations were attenuated in lag analyses, and no dose-response was observed.

IMPACT: Nocturia may reduce risk of bladder cancer among smokers. Further work is needed to confirm findings and understand mechanisms.

PMID:42536351 | DOI:10.1158/1055-9965.EPI-26-0300

Drugs Aging. 2026 Jul 31. doi: 10.1007/s40266-026-01324-7. Online ahead of print.

ABSTRACT

BACKGROUND: Loneliness is associated with high-risk medication use in older adults in cross-sectional studies, but the direction of this relationship is unclear.

OBJECTIVE: The aim of this study was to examine the association between loneliness and initiation of potentially inappropriate pain and psychotropic medications, and test for sex interactions.

METHODS: We conducted a retrospective cohort study of community-dwelling respondents to the Canadian Community Health Survey-Healthy Aging who were interviewed between December 1, 2008, and November 30, 2009, aged ≥66 years, and Ontario residents. Self-reported loneliness was defined at baseline as a score of ≥6 on the Three-Item Loneliness Scale. Survey responses were linked to health records; respondents were followed for 3 years to assess initiation of a potentially inappropriate pain or psychotropic medication, defined using the 2019 American Geriatrics Society’s Beers Criteria. We used weighted Cox proportional hazards regression models to estimate adjusted hazard ratios (HRs) and tested for sex interactions.

RESULTS: Of 2348 respondents (female 54.6%, mean age 75.4 years), 383 (12.3%) were lonely. Compared with those who were not lonely, lonely female respondents had higher rates of initiating potentially inappropriate pain medications (HR at 90 days: 1.57, 95% CI 0.96-2.27; 630 days: 1.52, 95% CI 1.05-2.12; 1080 days: 3.22, 95% CI 1.22-7.78) and potentially inappropriate psychotropic medications, but the latter estimates were imprecise. No association was found in males.

CONCLUSION: Lonely older females initiate potentially inappropriate pain and psychotropic medications at higher rates than those who are not lonely. Screening for loneliness could prioritize patients for medication reviews, possible deprescribing, and interventions that address root causes.

PMID:42536335 | DOI:10.1007/s40266-026-01324-7

Folia Microbiol (Praha). 2026 Jul 31. doi: 10.1007/s12223-026-01567-2. Online ahead of print.

ABSTRACT

Antibiotic resistance is the ability of microorganisms to survive and proliferate despite exposure to antibiotics that would normally inhibit or kill susceptible strains. This resistance can make antibiotics ineffective or diminish their ability to combat microorganisms, complicating the treatment of infections and potentially leading to serious complications. To combat antibiotic resistance, a comprehensive analysis of changes in the metabolic activities of microorganisms is crucial for understanding the underlying mechanisms. Proteus mirabilis is a critical pathogen, particularly as a common cause of urinary tract infections (UTIs), especially in women. Typically, treating P. mirabilis infections relies on antibiotic-based therapies. However, when faced with resistant strains, treatment options become limited. This research aims to simulate how antibiotic resistance develops in P. mirabilis when exposed to sub-inhibitory concentrations of ampicillin and to explore whether ampicillin-resistant strains display cross-resistance to other antibiotics through metabolomic approaches. For this purpose, P. mirabilis strains were gradually exposed to sub-inhibitory concentrations of ampicillin using the disk diffusion method, leading to the selection of resistant passages. Ampicillin and ceftazidime were then applied to both ampicillin-resistant passages and sensitive control strains, and differences in their metabolomic profiles were compared. The metabolomic data obtained from this study were supported by statistical and bioinformatics analyses to facilitate metabolic pathway mapping, comprehend metabolic alterations, and identify interactions among metabolites. Metabolomic studies in antibiotic resistance research provide valuable insights into identifying metabolic alterations in resistant microorganisms, understanding microbial responses to antibiotic exposure, clarifying the effects of antibiotics on metabolic pathways, and gaining a comprehensive perspective on the mechanisms of antibiotic resistance.

PMID:42536331 | DOI:10.1007/s12223-026-01567-2

Ann Nucl Med. 2026 Jul 31. doi: 10.1007/s12149-026-02255-4. Online ahead of print.

ABSTRACT

Partial volume effects (PVE) in positron emission tomography (PET) imaging introduce quantification inaccuracies, particularly in small or heterogeneous lesions, necessitating precise correction methodologies. This study systematically evaluates the performance of statistical versus machine learning approaches in partial volume correction (PVC) across multiple PET reconstruction algorithms, including TrueX, TrueX + TOF, and Iterative + TOF. Phantom experiments were conducted across a broad range of lesion-to-background contrast ratios and lesion sizes to derive and validate exponential recovery coefficient (RC) fitting models. Additionally, advanced machine learning algorithms, including Random Forest, Support Vector Regression, and Gradient Boosting, were implemented to enhance PVC accuracy. The results demonstrate that Iterative + TOF reconstruction yielded the most consistent RC estimates, while machine learning-based PVC significantly outperformed traditional exponential fitting in minimizing residual errors. Among the machine learning models, Random Forest exhibited the lowest root mean square error (RMSE) and highest coefficient of determination (R²), indicating superior predictive accuracy and robustness. These findings underscore the potential of machine learning-driven PVC methodologies for standardizing PET quantification, thereby improving lesion characterization, therapy response assessment, and multi-center data harmonization.

PMID:42536328 | DOI:10.1007/s12149-026-02255-4

Clin Rheumatol. 2026 Jul 31. doi: 10.1007/s10067-026-08325-2. Online ahead of print.

ABSTRACT

PURPOSE: The clinical benefit of combining leflunomide (LEF) with tumor necrosis factor inhibitors (TNFi) in psoriatic arthritis (PsA) remains uncertain. We aimed to evaluate the efficacy and treatment durability of LEF-TNFi compared with non-LEF regimens (predominantly methotrexate (MTX)-TNFi and TNFi monotherapy).

METHODS: This retrospective cohort included 492 biologic-naive PsA patients initiating TNFi (2003-2020): LEF-TNFi (n = 85) versus non-LEF (n = 407). Multiple imputation addressed missing data, and propensity score matching (7 covariates; caliper 0.2 standard deviations of the logit-propensity score) addressed confounding by indication. Longitudinal outcomes were analyzed using linear mixed-effects models; treatment modification was evaluated via Cox models. Reasons for treatment modification were examined descriptively using a competing risks framework.

RESULTS: Substantial baseline imbalances (23 of 36 variables with standardized mean difference > 0.10) were eliminated by propensity score matching (0 of 7 matching covariates with SMD > 0.10; 96.9% of LEF patients retained). Post-adjustment, longitudinal disease activity trajectories did not differ significantly between groups (time-by-treatment interactions: Disease Activity Score in 28 joints (DAS28), p = 0.862; Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), p = 0.308). Overall treatment modification rates were similar (propensity score-matched hazard ratio (HR) = 1.16; 95% confidence interval (CI), 0.53-2.51; p = 0.709). Descriptively, LEF patients were more frequently subject to treatment modification for remission (10.6% vs. 5.9%) and less frequently for inefficacy (5.9% vs. 11.1%), although cause-specific hazard ratios did not reach statistical significance.

CONCLUSION: After propensity score adjustment, LEF-TNFi showed no detectable difference in disease activity trajectories or overall treatment persistence compared with MTX-TNFi and TNFi monotherapy. However, LEF-TNFi modifications were predominantly driven by achieved remission rather than inefficacy. Keypoints • Propensity score-adjusted analyses revealed no detectable difference in disease activity trajectories between the LEF-TNFi, MTX-TNFi, and TNFi monotherapy groups in psoriatic arthritis. • Competing risks analysis showed that LEF modifications were driven by remission rather than inefficacy, a clinical distinction obscured by standard composite endpoints. • These hypothesis-generating findings suggest that LEF may be a viable alternative to MTX as concomitant csDMARD therapy with TNFi in PsA.

PMID:42536327 | DOI:10.1007/s10067-026-08325-2