Nevin Manimala

JAMA Netw Open. 2025 Feb 3;8(2):e2458155. doi: 10.1001/jamanetworkopen.2024.58155.

ABSTRACT

IMPORTANCE: During the COVID-19 pandemic public health emergency, states provided continuous Medicaid coverage to enrollees. In April 2023, states began to unwind this continuous coverage, prompting concern about the impact of this on pediatric patients.

OBJECTIVE: To examine loss of coverage during the unwinding of continuous Medicaid coverage among pediatric patients seen at community-based health care organizations.

DESIGN, SETTING, AND PARTICIPANTS: This cohort study with statistical analysis in November 2024 included pediatric patients from a multistate network of community-based health care organizations. Participants were aged up to 17 years at both their last Medicaid-insured visit during the continuous coverage period and at their first visit during the unwinding period (April 1, 2023, to March 31, 2024).

EXPOSURES: Age, sex, race and ethnicity, language, and medical complexity.

MAIN OUTCOME AND MEASURES: The main outcome was Medicaid disenrollment to uninsured status during the unwinding period. Logistic regression was used to estimate the odds of ever being uninsured during unwinding, and Cox proportional hazards regression models were used to examine the time to uninsured status from the start of unwinding in each patient’s state of residence through the end of March 2024. Associations between age, sex, race and ethnicity, language, and medical complexity and the outcome were assessed.

RESULTS: Among 450 146 pediatric patients, mean (SD) patient age was 8.11 (5.07) years and 50.1% were male. Overall, 8.7% were disenrolled from Medicaid to uninsured status. Patients aged 12 to 17 years had the highest estimated disenrollment among age groups (10.5%), but after adjustment, all other age groups had lower odds of disenrollment compared with those younger than 1 year. Females had higher odds of disenrollment (adjusted odds ratio [AOR], 1.15 [95% CI, 1.13-1.18]; adjusted hazard ratio [AHR], 1.14 [95% CI, 1.12-1.17]) than males. American Indian or Alaska Native patients had higher odds of disenrollment (AOR, 1.95 [95% CI, 1.81-2.09]; AHR, 1.81 [95% CI, 1.05-3.13]) than White patients, with estimated disenrollment of 17.1% vs 9.4%. Compared with patients with low medical complexity, those with either chronic but noncomplex (AOR, 1.83 [95% CI, 1.79-1.88]; AHR, 1.80 [95% CI, 1.44-2.27]) or complex chronic (AOR, 1.95 95% CI, 1.89-2.00]; AHR, 1.92 [95% CI, 1.67-2.21]) medical complexity had higher odds of disenrollment.

CONCLUSIONS AND RELEVANCE: In this cohort study of previously Medicaid-insured pediatric patients seen at community-based health care organizations, a meaningful proportion of patients were disenrolled to uninsured status during the unwinding of continuous Medicaid coverage, with associated differences by demographic and clinical characteristics. This could impact access to care and health outcomes for the patients.

PMID:39913136 | DOI:10.1001/jamanetworkopen.2024.58155

JAMA Netw Open. 2025 Feb 3;8(2):e2458160. doi: 10.1001/jamanetworkopen.2024.58160.

ABSTRACT

IMPORTANCE: The rising incidence of mental illness in the US underscores the need for timely access to psychiatric care, especially for vulnerable populations such as older adults and individuals with mental and physical disabilities who receive Medicare.

OBJECTIVE: To assess changes in the number and proportion of active psychiatrists providing professional services to traditional Medicare Part B enrollees from 2014 to 2022.

DESIGN, SETTING, AND PARTICIPANTS: This repeated cross-sectional study of Medicare Part B enrollees used publicly available data (for January 1, 2014, through December 31, 2022) from the Centers for Medicare & Medicaid Services and the Kaiser Family Foundation. Data from all traditional Medicare Part B enrollees in all 50 states and the District of Columbia were analyzed.

MAIN OUTCOMES AND MEASURES: Primary outcomes included changes in (1) the proportion of active psychiatrists billing traditional Medicare and (2) the number of psychiatrists providing care relative to the number of Medicare Part B enrollees nationally, regionally, and by state.

RESULTS: The study population comprised 291 748 472 Medicare Part B enrollee-years (33 042 936 in 2014: 5 800 903 [17.6%] eligible due to disability alone and 27 242 030 [82.4%] eligible due to age). From 2014 to 2022, the number of Medicare Part B enrollees decreased by 3 497 942 enrollee-years (10.6%), while the number of psychiatrists submitting more than 10 claims to Medicare Part B decreased by 3772 (16.8%). The nationwide proportion of professionally active psychiatrists submitting claims to Medicare Part B for professional services during this period declined from 22 409 of 50 416 (44.4%) in 2014 to 18 637 of 56 492 (33.0%) in 2022 (P < .001 on univariable regression). From 2014 to 2022, state-level changes in Medicare Part B-serving psychiatrists per enrollee ranged from a 31.7% increase in Alabama (from 36.5 to 48.1 psychiatrists per 100 000 enrollees) to a 67.8% decrease in Wyoming (from 42.9 to 13.8 psychiatrists per 100 000 enrollees). Every state and district assessed saw a decrease in the percentage of active psychiatrists who billed Medicare Part B for professional services over the study period.

CONCLUSIONS AND RELEVANCE: In this study of Medicare Part B acceptance among active US psychiatrists, declining acceptance of Medicare Part B for professional services among psychiatrists was observed nationally and across all states. During a time of psychiatrist workforce growth, the number of psychiatrists accepting traditional Medicare decreased, indicating potential challenges in providing equitable access to psychiatric care.

PMID:39913135 | DOI:10.1001/jamanetworkopen.2024.58160

Transl Vis Sci Technol. 2025 Feb 3;14(2):12. doi: 10.1167/tvst.14.2.12.

ABSTRACT

PURPOSE: A cross-sectional pilot study to compare macular oxygen saturation (sO2) and associated clinical measurements between normal and glaucoma subjects and to evaluate whether macular sO2 can be a diagnostic metric for early-stage glaucoma.

METHODS: Forty-eight eyes of 35 subjects from three groups were included: normal subjects (16 eyes, 10 subjects), suspect/pre-perimetric glaucoma (GS/PPG) subjects (17 eyes, 12 subjects), and perimetric glaucoma (PG) subjects (15 eyes, 13 subjects). We performed retinal oximetry of visible light optical coherence tomography (VIS-OCT) in macular vessels, with 512 × 256 sampling points over a 5 × 5 mm2 area. Zeiss Cirrus OCT scans and a 24-2 visual field test (VFT) were conducted. Statistical analysis was conducted.

RESULTS: Significant differences were observed among the three groups for all VIS-OCT, Zeiss OCT, and VFT variables. As glaucoma severity increased, macular AsO2 (arterial sO2) and A-V sO2 (arteriovenous sO2 difference) decreased, whereas macular VsO2 (venous sO2) increased. Macular AsO2 and A-V sO2 were found to be statistically correlated with ganglion cell layer + inner plexiform layer (GCL+IPL) and circumpapillary retinal nerve fiber layer in all eyes, as well as in PG eyes. Within the PG group, a dominant correlation between AsO2 and ganglion cell layer + inner plexiform layer was observed in the more damaged lower hemifield.

CONCLUSIONS: Glaucoma subjects showed altered macular sO2, indicating reduced oxygen consumption. The sO2 measured by VIS-OCT could be a potential metric for early glaucoma diagnosis.

TRANSLATIONAL RELEVANCE: This study shows macular sO2 measurements via VIS-OCT could bridge advanced imaging technology and clinical glaucoma detection.

PMID:39913123 | DOI:10.1167/tvst.14.2.12

Int Braz J Urol. 2025 Mar-Apr;51(2):e20240498. doi: 10.1590/S1677-5538.IBJU.2024.0498.

ABSTRACT

PURPOSE: To evaluate the effect of real-time self-visualisation (SV) of the procedure during flexible cystoscopy (FC) on pain and anxiety in male and female patients with no prior cystoscopy history.

PATIENTS AND METHODS: Between Dec 2022-May 2024, 400 patients who underwent office-based FC were enrolled into prospective randomized study in accordance with CONSORT. Patients were randomised into two groups (SV and no-SV) using sequential (1:1 ratio) randomisation. To ensure equal numbers of male and female patients in each group, one consecutive male patient was assigned to the SV group, while the next male patient was assigned to the non-SV group; the same randomization was done for females. The primary endpoint was to evaluate the pain during FC (during urethral insertion of the cystoscope and bladder examination stages) of both groups. The secondary endpoint was to evaluate anxiety, patient satisfaction, and willingness to undergo the procedure of both groups.

RESULTS: In males, significant lower pain scores were detected in SV group during urethral insertion of the cystoscope (1.4 vs. 4.8, p<0.001) and during bladder examination (0.9 vs. 3.1, p<0.001). However, pain scores during urethral insertion of the cystoscope (1.9 vs. 2, p=0.38) and during bladder examination (1.2 vs. 1.3, p=0.63) were statistically similar between two groups in female patients. In both genders, significant lower anxiety levels, higher patient satisfaction and higher willingness to undergo repeat cystoscopy were detected in SV group.

CONCLUSION: SV during FC may be beneficial in reducing pain in male patients but not in female patients. SV during FC has a positive effect on anxiety, patients’ satisfaction, and willingness to undergo repeat procedures, regardless of gender.

PMID:39913099 | DOI:10.1590/S1677-5538.IBJU.2024.0498

Int Braz J Urol. 2025 Mar-Apr;51(2):e20240630. doi: 10.1590/S1677-5538.IBJU.2024.0630.

ABSTRACT

PURPOSE: The accurate diagnosis of prostate cancer (PCa) remains challenging, particularly because standard biopsy techniques do not routinely include anterior zone, leading to potential missed diagnoses in this region. This study evaluates the accuracy and safety of biplanar stereotactic biopsy for diagnosing anterior clinically significant PCa (csPCa).

MATERIALS AND METHODS: After propensity score matching analysis, data from 256 patients were retrospectively analyzed, including 128 in the biplanar group (transrectal targeted biopsy with transperineal systematic biopsy) and 128 in the monoplanar group (transperineal targeted biopsy with transperineal systematic biopsy). PCa detection rates, lesion locations, csPCa, clinically insignificant PCa (ciPCa), and complication incidences were compared. Univariable and multivariable logistic regression models evaluated factors influencing biopsy outcomes.

RESULTS: No significant differences were observed in overall PCa detection, ciPCa, posterior lesions, or postoperative complications between biplanar and monoplanar groups. The biplanar group demonstrated a higher detection rate for anterior csPCa (P=0.025). The overall International Society of Urological Pathology grade group (ISUP GG) distributions for Prostate Imaging Reporting and Data System (PI-RADS) scores 3 to 5 were not significantly different. Logistic regression identified age and PSA levels as independent predictors of higher detection rates, while univariable analysis showed that prostate volume had a significantly smaller effect on PCa detection rates in the biplanar group compared to the monoplanar group. Postoperative complications showed no statistically significant differences.

CONCLUSIONS: In conclusion, biplanar stereotactic biopsy was superior to monoplanar biopsy in detecting anterior csPCa. Both methods demonstrated no significant differences in overall PCa detection rates and safety.

PMID:39913095 | DOI:10.1590/S1677-5538.IBJU.2024.0630

Int Braz J Urol. 2025 Mar-Apr;51(2):e20240565. doi: 10.1590/S1677-5538.IBJU.2024.0565.

ABSTRACT

BACKGROUND: Different modalities of percutaneous thermal ablation (PTA) have been used as possible minimally invasive nephron-sparing treatments for small renal masses (SRMs). The present study aimed to compare long-term outcomes of two guidelines-recommended ablative techniques, cryotherapy (CRYO) and radiofrequency ablation (RFA).

MATERIALS AND METHODS: Data of patients with single cT1 solid renal mass undergoing CRYO or RFA between 2004 and 2020 were retrospectively retrieved from a multi-institutional international database. Oncologic outcomes included “technical success”, local recurrence-free survival (RFS), distant metastasis-free survival (MFS), and overall survival (OS). Intraoperative and postoperative complications, length of stay (LOS), and re-admission rate within 30 days were registered. Major complications were defined as CD grade ≥III. Baseline features and treatment outcomes were analyzed using descriptive statistics. RFS, MFS, and OS were estimated using the Kaplan-Meier method.

RESULTS: Overall, 643 patients were included, of which 492 (71.2%) underwent CRYO, and 151 (21.8%) RFA, with a median follow-up of 43 and 37 months, respectively (p=0.07). Technical success was achieved in 96.5% of CRYO vs 93.4% of RFA (p=0.09). No difference in terms of overall (CRYO: 10.4% vs RFA: 6%; p=0.1) and “major” (CRYO: 0.8% vs RFA: 1.3; p=0.06) post-operative complications were observed. RFS (CRYO:85.7%; RFA:84.9%, p=0.2), MFS (CRYO: 96.9%; RFA: 95.8%, p=0.4) and OS (CRYO: 89%; RFA: 87.4%; p=0.8) were comparable.

CONCLUSIONS: CRYO and RFA are both valid minimally invasive options for the treatment of small renal tumors. They are particularly suitable for patients who are not good surgical candidates as they offer very low risk of major procedure-related complications. For the right indication, they both offer favorable mid to long term oncologic outcomes.

PMID:39913094 | DOI:10.1590/S1677-5538.IBJU.2024.0565

Int Braz J Urol. 2025 Mar-Apr;51(2):e20240425. doi: 10.1590/S1677-5538.IBJU.2024.0425.

ABSTRACT

PURPOSE: Non-neurogenic overactive bladder (OAB) is a common problem in children. Antimuscarinics have been widely used as first-line medical treatment. However, their frequent side effects necessitate searching for therapeutic alternatives. We aimed to assess the efficacy and safety of the beta 3 agonist, mirabegron.

MATERIALS AND METHODS: A randomized controlled trial enrolled child with non-neurogenic OAB refractory to behavioral urotherapy. Patients were randomized to receive either Mirabegron 25/50 mg based on a 40-kg body weight cutoff or solifenacin 5 mg for 12 weeks. Patients were assessed using Dysfunctional Voiding Scoring System questionnaire (DVSS), 3-day voiding diary and uroflowmetry. Vital signs and adverse effects were recorded at baseline and follow-up. The study primary endpoint was ≥50% reduction of the baseline DVSS.

RESULTS: Among 128 patients screened, 72 patients (36 in each group) completed the study with a mean age of 9.2±2.3 years. Both groups had significant improvement of DVSS and voiding diary (p<0.001) at 12 weeks. In mirabegron group, 94.4% (34/36) had greater than 50% improvement of DVSS compared to 75% (27/36) of solifenacin group (P=0.02). Complete symptom resolution was observed in 22.2% (8/36) patients on mirabegron versus 8.3% (3/36) on solifenacin (P=0.1). Patients on mirabegron had less adverse effects (19.4% vs 47.2%; p=0.01).

CONCLUSION: Mirabegron is more effective with fewer adverse effects than solifenacin for treatment of children with OAB. Mirabegron treatment improves daytime symptoms and nocturnal enuresis with less risk of constipation. It may be considered as first-line pharmacotherapy in this patient population.

PMID:39913092 | DOI:10.1590/S1677-5538.IBJU.2024.0425

Int Braz J Urol. 2025 Mar-Apr;51(2):e20240332. doi: 10.1590/S1677-5538.IBJU.2024.0332.

ABSTRACT

PURPOSE: There is substantial literature demonstrating minimal to no increased risk of three-piece penile prosthesis (PP) complications for patients undergoing placement with concomitant reconstructive urologic procedures. However, there is a paucity of research investigating outcomes for patients suffering from erectile dysfunction (ED) who undergo concomitant non-reconstructive urologic procedures at the time of PP placement.

MATERIALS AND METHODS: We performed a retrospective review of patients undergoing PP placement and a second non-reconstructive urologic procedure performed concomitantly at our institution between January 2007 and July 2021. This was compared to a control cohort of 127 patients who underwent PP placement only. Outcomes of interest were complications and device infections. Comparative statistics were used to compare the two groups, and the Kaplan-Meier method was used to estimate the rate of complications and infections over time.

RESULTS: We identified 44 patients who underwent concomitant surgery and 127 patients who underwent single surgery only. The types of concomitant surgeries were as follows: 23 endoscopic (52.3%), 9 penile (20.5%), 10 scrotal (22.7%), 1 hardware placement (2.3%), and 1 oncologic (2.3%). Hypertension was the only comorbidity that was more prevalent in the concomitant group (65.9% vs. 43.8%, P < 0.01). Patients undergoing concomitant surgery had similar complication (4.6% vs. 3.6%, P=0.79) and device infection (2.3% vs. 0.7%, P=0.43) rates as the single surgery group.

CONCLUSIONS: In the largest study of its kind, we observed that patients undergoing concomitant non-reconstructive urologic procedures at the time of PP placement are not at an increased risk of adverse events.

PMID:39913091 | DOI:10.1590/S1677-5538.IBJU.2024.0332

Int Braz J Urol. 2025 Mar-Apr;51(2):e20240490. doi: 10.1590/S1677-5538.IBJU.2024.0490.

ABSTRACT

PURPOSE: Radical cystectomy (RC) is the standard of care for patients with bladder cancer, and pelvic lymph node dissection (PLND) is a pivotal step that can be carried out either before or after RC. Evidence on the optimal timing for PLND remains limited.

MATERIALS AND METHODS: We searched PubMed, Embase, Cochrane Central, Scopus and Google Scholar for studies comparing PLND before versus after RC. Outcomes assessed were total operative time, PLND time, RC time, number of lymph nodes (LN) dissected, and estimated blood loss. Mean differences (MDs) and 95% confidence intervals (CIs) were computed using a random-effects model. Subgroup analysis was conducted for robot-assisted RC (RARC).

RESULTS: A total of 801 patients from six studies were included, of whom 360 (44.94%) underwent PLND before RC. There were no significant differences in total operative time (MD -17.49; 95% CI -41.65,6.67; p = 0.16; I2 = 94%), PLND time (MD -14.91; 95% CI -44.91,15.09; p = 0.33; I2 = 96%), LN yielded (MD -1.13; 95% CI -4.81,2.55; p = 0.55; I2 = 83%), and estimated blood loss (MD 0.17; 95% CI -51.33,51.68; p = 0.99; I2 = 81%). However, RC time was significantly reduced (MD -28.89; 95% CI -42.84,-14.93; p < 0.0001; I2 = 75%) when PLND was performed prior to RC. In RARC studies, PLND before RC decreased total operative time, RC time, and estimated blood loss.

CONCLUSIONS: The timing of lymphadenectomy was not associated with a significant reduction in total operative time, PLND time, LN yield, and estimated blood loss.

PMID:39913090 | DOI:10.1590/S1677-5538.IBJU.2024.0490

Cerebellum. 2025 Feb 6;24(2):43. doi: 10.1007/s12311-025-01792-4.

ABSTRACT

Cerebellar functional connectivity changes have been reported in Alzheimer’s disease (AD), but a comprehensive framework integrating these findings is lacking. This retrospective study investigates the cerebello-thalamo-cortical (CTC) circuit in AD, using functional gradient analysis to elucidate deficits and potential biomarkers. We analyzed data from 246 participants enrolled in the Alzheimer’s Disease Neuroimaging Initiative (ADNI-3; NCT02854033), including 58 with AD, 103 with mild cognitive impairment (MCI), and 85 cognitively normal (CN) controls, matched for age and sex. All individuals underwent comprehensive neuropsychological assessments (MMSE, MoCA, ADAS-Cog) and MRI scans. We extracted mean time series for 270 brain regions (an extended Power atlas) and computed pairwise functional connectivity, focusing on CTC circuitry. Thalamic and cerebellar connectivity gradients were derived using voxel-wise correlation matrices and the BrainSpace toolbox, defining thalamic and cerebellar masks from the Melbourne subcortical atlas and AAL atlas, respectively. ANCOVA with post hoc analyses, controlling for age and sex, was conducted to assess abnormal CTC connectivity across AD, MCI, and CN groups. LASSO regression identified edges within the CTC circuitry that significantly differed between AD and CN, MCI and CN, AD and MCI, as well as was used to construct Logistic classification model. Pearson correlations were performed to examine relationships between mean CTC connectivity, individual edges, and cognitive scores (MMSE, MoCA, ADAS-Cog). To explore the hierarchical organization of the thalamus and cerebellum, global gradient distributions were compared across groups using two-sample Kolmogorov-Smirnov tests. Additionally, ANCOVA was applied to compare subfield- and functional-level gradients of the thalamus and cerebellum among AD, MCI, and CN. False discovery rate (FDR) corrections were used, setting the statistical significance threshold was set at P < 0.05. AD and MCI individuals exhibited increased CTC connectivity compared to CN (all P < 0.05). Average CTC connectivity did not correlate with cognitive scores (P > 0.05), but specific CTC edges were correlated. LASSO regression identified 20 discriminative edges, achieving high accuracy in AD-CN classification (AUC = 0.92 training, AUC = 0.80 test). Thalamic and cerebellar gradient distributions differed significantly across groups (all P < 0.05), with specific regions showing distinct gradient scores. Five cerebellar functional networks exhibited decreased gradient scores. Significant CTC hyperconnectivity in AD and MCI compared with CN suggests early thalamic and cerebellar dysregulation. Classification analyses effectively distinguished AD vs. CN but were moderate for MCI vs. CN and limited for MCI vs. AD. Gradient analyses revealed global- and subfield-level disruptions in AD, emphasizing the role of thalamic and cerebellar interactions in cognitive decline and offering potential diagnostic markers and therapeutic targets.

PMID:39913059 | DOI:10.1007/s12311-025-01792-4