Nevin Manimala

Neurology. 2026 Jun 9;106(11):e218067. doi: 10.1212/WNL.0000000000218067. Epub 2026 May 8.

ABSTRACT

BACKGROUND AND OBJECTIVES: Patients with multiple sclerosis (MS) require increasing health care support, particularly in the last year of life. Despite the benefits of palliative care in addressing symptom burden and improving quality of life, its integration into MS care remains inconsistent. This study aimed to characterize health care utilization and palliative care access among people with MS in the last years of life and to identify key factors associated with hospital death and receipt of palliative care.

METHODS: A retrospective cohort study was conducted using linked health administrative databases in Ontario, Canada. The cohort consisted of all decedents aged 18 years or older who died in Ontario between April 2016 and March 2020, and we compared health care utilization in decedents with MS to the rest of the cohort. The identification of MS cases was based on a validated algorithm. Demographics, health care utilization, palliative care involvement, and medical interventions were analyzed. Predictors of palliative care receipt and hospital deaths were evaluated using multivariable logistic regression models.

RESULTS: MS decedents (n = 1,975; mean age 68 years; 66.4% female) were younger and had fewer comorbidities than non-MS decedents (n = 500,904; mean age 77). High percentage of MS decedents had outpatient neurology visits in the last 5 years of life (49.4%) but a steep decline closer to death (2.7% in the last month). Palliative care use was similar (58.0% vs 56.9%) but occurred earlier in MS (61.9% vs 59.6% in the last 5 years). Multivariable regression showed that rural residence was associated with increased odds of hospital death (odds ratio [OR] 1.81, 95% CI 1.21-2.70) and lower odds of receiving palliative care (OR 0.74, 95% CI 0.55-0.99), while receiving palliative care within the last 5 years of life reduced the odds of hospital death (OR 0.47, 95% CI 0.37-0.60). Higher comorbidity and increased outpatient visits to urology were associated with a greater odd of receiving palliative care (OR 3.64, 95% CI 2.50-5.29 and OR 1.47, 95% CI 1.20-1.80).

DISCUSSION: Although palliative care receipt was comparable between MS and non-MS decedents, rural disparities and high hospital deaths persist. Earlier palliative integration, particularly through neuropalliative care, could improve quality of life and reduce hospitalizations.

PMID:42102338 | DOI:10.1212/WNL.0000000000218067

J Pediatr Orthop. 2026 May 8. doi: 10.1097/BPO.0000000000003313. Online ahead of print.

ABSTRACT

BACKGROUND: Free fibular flaps (FFF) and pedicled fibular grafts (PFG) are established techniques for reconstructing pediatric long bone defects. While the FFF provides versatility through microvascular transfer, PFGs avoid anastomosis but are limited by anatomic constraints. Clinical questions remain regarding optimal fixation strategies, donor-site morbidity, and graft outcomes in children.

METHODS: This retrospective cohort study analyzed 22 pediatric patients undergoing FFF or PFG between 1994 and 2025. Outcomes included time to radiographic union, time to weight bearing, fibular regeneration, and donor-site complications. Subgroup analyses compared external fixation use, periosteal sleeve preservation, and graft type/location.

RESULTS: The average time to radiographic union was 41 weeks. External fixation was associated with shorter radiographic union time (30.1 vs. 86.4 wk) and earlier full weight bearing on the graft-receiving limb (52.0 vs. 127.2 d), though these findings should be interpreted as exploratory given the limited sample size and inconsistent significance across statistical tests. Younger patient age correlated with faster union (r = 0.60, P = 0.004). Preservation of a periosteal sleeve at the donor site significantly promoted fibular regeneration (P = 0.0004) and may hasten donor limb recovery. Ankle valgus deformity was associated with shorter residual distal fibula length (mean 5.6 cm, P = 0.0498). All grafts showed remodeling over time. Tibial graft location and use of PFG were significantly associated with need for refixation (P = 0.0001 and P = 0.0002, respectively).

CONCLUSION: Pediatric FFF reconstruction demonstrates high union and remodeling rates with favorable functional outcomes. External fixation was found to be weakly associated with acceleration of union and weight bearing, while periosteal sleeve preservation supports fibular regeneration and potentially expedites return to weight bearing on the donor limb. PFGs may be effective in select tibial cases but showed higher reoperation rates. Preserving an adequate distal fibula segment may mitigate ankle valgus. These findings support tailored fixation strategies and highlight the importance of surgical planning to optimize outcomes and minimize donor-site morbidity in pediatric patients.

LEVEL OF EVIDENCE: Level III-therapeutic study.

PMID:42102320 | DOI:10.1097/BPO.0000000000003313

JMIR Nurs. 2026 May 8;9:e87930. doi: 10.2196/87930.

ABSTRACT

BACKGROUND: Understanding current nursing workflows is essential to informing future workforce redesign strategies, including virtual nursing roles. However, granular insights into current nursing workflows over a 24-hour period and across different staff grades are lacking.

OBJECTIVE: This study aimed to (1) quantify how registered and enrolled nurses in the general acute medicine wards distribute their time across direct and indirect care tasks over a 24-hour period, (2) identify multitasking burdens and temporal distributions, and (3) identify opportunities for the development of a virtual nursing role.

METHODS: Using time-and-motion methodology, we observed registered and enrolled nurses in 3 general medicine wards over a 24-hour period between April 2024 and June 2024. We observed 3 task categories (administrative, communication, and bedside tasks), with multiple individual tasks monitored under each category. Multitasking (ie, the occurrence of 2 or more tasks concurrently) was also tracked. The checklist was piloted and refined before data collection.

RESULTS: We observed a total of 48 nursing shifts. During the daytime, registered nurses spent 70% (587/834 min) of their time on indirect care tasks compared with 54% (412/764 min) of the time for enrolled nurses. At night, the proportion of time spent on indirect care tasks decreased to 58% (410/705 min) for registered nurses and 39% (274/711 min) for enrolled nurses. During a 24-hour period, registered nurses spent 209 (SD 51.8) minutes multitasking in the day and 117 (SD 41.0) minutes at night, whereas enrolled nurses spent 152 (SD 54.7) minutes multitasking in the day and 110 (SD 75.9) minutes at night.

CONCLUSIONS: These findings highlight opportunities for virtual nursing roles, which, if thoughtfully designed, may help redistribute indirect care tasks, reduce multitasking burden, and enhance overall efficiency without compromising care quality.

PMID:42102318 | DOI:10.2196/87930

J Pediatr Orthop. 2026 May 8. doi: 10.1097/BPO.0000000000003306. Online ahead of print.

ABSTRACT

BACKGROUND: This study aimed to identify all pediatric femoral neck fractures and determine the prevalence of autism spectrum disorder (ASD) and other neurodevelopmental disorders (NDD) among these patients. In addition, it aimed to assess their impact on clinical and radiographic outcomes.

METHODS: A total of 289 pediatric patients with proximal femoral fractures were initially identified, of whom 140 met the inclusion criteria for femoral neck fractures after excluding pathologic fractures, polytrauma, and incomplete records. Demographic, clinical, and radiographic data, including the presence of ASD and other NDD conditions, were collected. Intraoperative and postoperative complications were recorded. Statistical analyses were performed using (IBM SPSS Statistics; IBM Corp., Armonk, NY) with associations between variables assessed using t tests and χ2 tests, and significance set at P<0.05.

RESULTS: Among 140 pediatric patients with femoral neck fractures, 39 (28%) were diagnosed with ASD or NDD. Compared with non-ASD patients, those with ASD exhibited more frequent additional neurological and gastrointestinal/endocrinologic comorbidities, higher prevalence of low preoperative vitamin D levels, and a greater incidence of home-related injuries (all P<0.05). Intraoperative and postoperative complications, including infection and avascular necrosis, were infrequent and did not differ significantly between groups. The mean time for return to daily activities was similar between ASD and non-ASD patients.

CONCLUSION: A significant association was observed between pediatric femoral neck fractures and ASD or other NDD, including intellectual disabilities. Children with ASD or NDD demonstrated higher rates of medical comorbidities, low preoperative vitamin D levels, and home‑related injuries, suggesting unique risk profiles in this population.

LEVEL OF EVIDENCE: Level III.

PMID:42102315 | DOI:10.1097/BPO.0000000000003306

Biomol Biomed. 2026 May 8. doi: 10.17305/bb.2026.14216. Online ahead of print.

ABSTRACT

Dynamic retinal vessel analysis is a non-invasive approach for assessing retinal microvascular endothelial function, yet the extent to which eye selection, interocular variability, and systemic physiological factors influence dynamic retinal vessel analyzer (DRVA)-derived biomarkers remains insufficiently defined. This prospective methodological study aimed to evaluate the interocular symmetry and absolute and relative reliability of arterial flicker-induced dilation (aFID), venular flicker-induced dilation (vFID), and arteriolar constriction (aCON), and to determine whether these parameters are moderated by eye dominance, peak oxygen uptake (V̇O₂ peak), or intraocular pressure (IOP) in healthy individuals. Twenty apparently healthy adults completed two laboratory visits. During the first visit, aerobic capacity was assessed by cardiopulmonary exercise testing until volitional exhaustion. During the second visit, IOP, resting blood pressure, eye dominance, and retinal vascular endothelial function were assessed using DRVA in both eyes in randomized order. Interocular differences were examined using paired comparisons, Bland-Altman analysis, reliability statistics, and linear mixed-effects models accounting for bilateral measurements within participants. No significant differences were observed between the left and right eyes for aFID, vFID, or aCON. Bland-Altman analysis showed no systematic interocular bias across DRVA-derived parameters, although the limits of agreement were widest for aFID, indicating greater interocular variability. Relative reliability was highest for vFID, followed by aCON, whereas aFID showed only fair agreement. Similarly, absolute reliability analyses identified vFID as the most stable biomarker, with the lowest coefficient of variation, while aFID demonstrated the greatest variability. Linear mixed-effects models showed no significant moderating effects of eye dominance, V̇O₂ peak, or IOP on aFID, vFID, or aCON. These findings suggest that retinal vascular endothelial responses measured by DRVA are not systematically influenced by eye dominance or selected systemic physiological factors in healthy young adults. However, given the observed interocular variability, particularly for aFID, assessment of both eyes should be considered in clinical and research settings to improve measurement precision and reproducibility.

PMID:42102314 | DOI:10.17305/bb.2026.14216

Am J Occup Ther. 2026 Jul 1;80(4):8004205080. doi: 10.5014/ajot.2026.051493.

ABSTRACT

IMPORTANCE: Sleep health supports child development and family well-being. Toddlers with Down syndrome experience elevated sleep difficulties, yet few studies have examined their sleep within a multidimensional framework.

OBJECTIVE: To apply the Pediatric Sleep Health framework (Peds B-SATED) to characterize multidimensional sleep health and sleep-related practices of toddlers with Down syndrome (12-36 mo).

DESIGN: Secondary analysis of cross-sectional descriptive data.

SETTING: Clinics and organizations serving families of children with Down syndrome.

PARTICIPANTS: Twenty-four mothers of children with Down syndrome were recruited.

OUTCOMES AND MEASURES: Parent-reported Brief Infant Sleep Questionnaire items mapped onto the Peds B-SATED domains (Behavior, Satisfaction, Alertness, Timing, Efficiency, Duration). Descriptive statistics summarized sleep profiles and parental practices.

RESULTS: Fifty percent of the sample demonstrated multidomain sleep difficulties; 33% had difficulties in a single domain, and 17% had none. Behavior was the most problematic domain (63%), followed by satisfaction and efficiency (29% each), timing (25%), and duration (13%). Most children had structured sleep behaviors (consistent bedtimes/routines ≥80%; falling asleep independently, 70%; limited prebedtime screen exposure, 67%) and high parental satisfaction. Most children woke up happy and took one daytime nap (>90%). Sleep timing and efficiency were characterized by early bedtimes (median lights-out 8 p.m.; median wake 7 a.m.), no night awakenings (71%), and mean sleep latency of 13.5 min. Mean 24-hr sleep duration was 12.5 hr.

CONCLUSIONS AND RELEVANCE: A multidimensional approach to characterizing sleep health reveals heterogeneous sleep profiles across domains and offers clinicians and researchers an in-depth view of intervention targets for toddlers with Down syndrome. Plain-Language Summary: This study examined the sleep health of toddlers with Down syndrome ages 12-36 months by using the Pediatric Sleep Health framework, which looks at multiple aspects of sleep, including routines, quality, timing, and duration. Parents of 24 children completed a questionnaire about their child’s sleep, and then we mapped their responses to this sleep health framework. We found that most children went to bed and woke up early, slept about 12.5 hr per day, and were described as good sleepers. However, many children had at least one area of difficulty, most often related to bedtime behaviors (63%). In general, about 17% had no sleep-related concerns, whereas the remainder experienced challenges in one or more areas. These findings show that even when overall sleep appears good, specific sleep behaviors may still benefit from attention. Using a multidimensional sleep health framework can help identify these patterns and better describe sleep health of young children with Down syndrome.

PMID:42102306 | DOI:10.5014/ajot.2026.051493

JMIR Mhealth Uhealth. 2026 May 8;14:e72242. doi: 10.2196/72242.

ABSTRACT

BACKGROUND: In the management of gestational diabetes mellitus (GDM), the usual medical treatment requires frequent visits for glucose monitoring and insulin dose adjustment, and this imposes significant physical, psychological, and economic burdens on pregnant women. As mobile health platforms become increasingly integrated into diabetes care, telemedicine may help alleviate these burdens; however, evidence evaluating its effectiveness as a replacement for routine in-person GDM care remains limited.

OBJECTIVE: This study aims to evaluate the impact of telemedicine on the quality of life and costs for patients with GDM requiring insulin therapy.

METHODS: This single-center, 2-arm, randomized, open-label, parallel-group study included patients with GDM who started insulin injection therapy. Participants were randomized to either the telemedicine or standard face-to-face care groups for 10 (SD 2) weeks. The telemedicine intervention used a smartphone-linked platform that enabled the automatic transfer of glucose data from connected glucose meters and facilitated real-time video consultations. Primary end points included costs and patient satisfaction. Costs were assessed using claims data, transportation calculations, and wage-based productivity losses, while patient satisfaction was evaluated through changes in the Problem Areas in Diabetes Survey and Diabetes Therapy-Related Quality of Life questionnaire scores. Secondary outcomes included glycemic control and perinatal outcomes.

RESULTS: In total, 38 participants were included, with 18 assigned to the telemedicine group and 20 to the standard care group. Total costs (32,712, 95% CI 15,412-50,013 vs 59,202, 95% CI 42,603-75,800 Japanese yen; $284, 95% CI 134-435 vs $515, 95% CI 370-659, purchasing power parity [PPP]-adjusted; P=.01), direct non-health care costs (922, 95% CI -240 to 2084 vs 2561, 95% CI 1447-3676 yen; $8, 95% CI -2 to 18 vs $22, 95% CI 13 to 32 PPP-adjusted; P=.02), and indirect costs (8981, 95% CI -7119 to 25,082 vs 32,832, 95% CI 17,384-48,279 yen; $78, 95% CI -62 to 218 vs $285, 95% CI 151-420 PPP-adjusted; P=.01) reduced significantly in the telemedicine group compared with the standard care group. The improvements in the Problem Areas in Diabetes Survey (-7.6, 95% CI -13.7 to -1.4; P=.02) and Diabetes Therapy-Related Quality of Life domain 1 (10.5, 95% CI 0.9-20.1; P=.03) scores from the baseline were significantly greater in the telemedicine group than that in the standard care group. Nonetheless, glycemic control and frequency of perinatal complications were comparable between the 2 groups. Consultation time was similar across groups, suggesting no added workload for clinicians.

CONCLUSIONS: In this randomized trial, mobile health-enabled telemedicine safely replaced routine in-person visits for patients with GDM requiring insulin therapy. Telemedicine significantly reduced psychological and economic burdens without compromising glycemic or perinatal outcomes, demonstrating its value as a patient-centered and cost-efficient model of care. These findings support the broader implementation of mobile-based telemedicine approaches in GDM management.

PMID:42102285 | DOI:10.2196/72242

JMIR Form Res. 2026 May 8;10:e92644. doi: 10.2196/92644.

ABSTRACT

BACKGROUND: Childhood obesity constitutes a complex medical and psychosocial challenge that requires both nutritional knowledge and sensitive, relationship-oriented doctor-patient communication. The Planetary Health Diet links individual health promotion with environmental sustainability and represents a relevant framework for contemporary medical education.

OBJECTIVE: This proof-of-concept study investigated how different information sources influence medical students’ acquisition, structuring, and application of knowledge on childhood obesity and the Planetary Health Diet within a communication-based teaching setting, including the exploratory use of artificial intelligence-based tools.

METHODS: A total of 359 second-year medical students participated in a mandatory communication seminar during the 2023-2024 academic year. Following a precourse knowledge assessment and a brief theoretical introduction, students worked on a standardized counseling scenario addressing childhood obesity. In small groups, students used only 1 assigned information source (ChatGPT, Google Search, scientific papers, or instructional videos) to prepare a counseling approach. Group outcomes were assessed using a predefined scoring system based on a sample solution, complemented by thematic content analysis.

RESULTS: All information sources enabled students to acquire relevant knowledge on childhood obesity and the Planetary Health Diet. However, groups differed with regard to the depth, differentiation, and structuring of their responses. The ChatGPT group achieved the highest conformity scores with the sample solution and provided the most additional information, followed by the Google and video groups, while the paper group achieved the lowest scores. Prior to the course, students reported limited knowledge of the Planetary Health Diet and little practical experience in counseling children with obesity and their families.

CONCLUSIONS: Communication-based teaching formats provide an effective framework for introducing medical students to complex topics such as childhood obesity and sustainability-related nutrition early in their training. Easily accessible digital tools, including artificial intelligence-based systems, may facilitate knowledge acquisition and elaboration; however, their use requires explicit didactic framing, critical source evaluation, and reflection on the complexity of chronic conditions to support responsible and realistic learning outcomes in future physicians.

PMID:42102283 | DOI:10.2196/92644

JMIR Form Res. 2026 May 8;10:e79735. doi: 10.2196/79735.

ABSTRACT

BACKGROUND: Marijuana initiation among adults aged 50 years and older has increased substantially. Although acute tetrahydrocannabinol exposure can impair psychomotor function, less is known about how real-world medical marijuana initiation relates to functional tasks such as driving in mid-to-late life.

OBJECTIVE: The objective of our study was to evaluate the feasibility of recruiting and retaining adults aged 50 years and older, who are newly registered for medical marijuana, and matched non-marijuana-using controls, into a longitudinal high-fidelity driving simulator protocol, and to explore preliminary associations between medical marijuana initiation and simulated driving performance.

METHODS: This prospective, nonrandomized feasibility cohort study enrolled adults aged 50 years and older who are newly registered in the Florida Medical Marijuana Use Registry, along with age-, race-, and sex-matched controls. Assessments occurred at baseline (T1; preinitiation) and at 1 month (T2). Primary feasibility outcomes included recruitment, retention, simulator completion and tolerance, and exposure verification. Exploratory outcomes included reaction time and divided attention (DA) performance, which are measured using an immersive, high-fidelity driving simulator.

RESULTS: Recruitment and exposure verification procedures were feasible, but simulator sickness contributed to substantial missing data. Exploratory analyses suggested group differences in select DA outcomes at T2. At T2, reaction time to DA situation 3 (DA3) was significantly shorter in the medical marijuana group (n=14, mean 2.57, SD 1.63) than in the control group (n=7, mean 5.79, SD 4.32; t19=-2.50, P=.02, g=-1.11, 95% CI -2.04 to -0.16). These findings should be interpreted cautiously, given the small sample size, missing data, and multiple comparisons.

CONCLUSIONS: A prospective protocol examining medical marijuana initiation and simulated driving among mid-to-late-life adults is feasible, but future studies should incorporate design and analytic refinements to address simulator sickness and missing data and to better characterize exposure timing and patterns.

PMID:42102282 | DOI:10.2196/79735

JMIR Cancer. 2026 May 8;12:e86412. doi: 10.2196/86412.

ABSTRACT

BACKGROUND: Wearable devices are becoming more ubiquitous and are capable of capturing health-relevant information that patients may be interested in sharing with their providers. However, limited research has been conducted on oncology provider perspectives on how these data could be used to inform cancer care.

OBJECTIVE: The goal of this study was to understand oncology clinicians’ preferences about which data would be most clinically valuable and in what clinical scenarios, the benefits and barriers to integrating wearable device data into cancer care, and perspectives on how wearable device data could impact decision-making using 3 clinical vignettes.

METHODS: A total of 13 oncology care clinicians completed an online questionnaire to assess the perceived value of different types of wearable device data in different clinical scenarios and participated in semistructured interviews to gather preferences around integrating these data into clinical workflows. During the interviews, providers were also presented with 3 clinical vignettes and asked for clinical recommendations both before and after seeing the patient’s wearable device data. Descriptive statistics were calculated to summarize quantitative data from questionnaires and structured interview questions, and interviews were transcribed and coded using an iterative thematic analysis approach.

RESULTS: Survey responses indicated that providers were most interested in tracking vital sign metrics, followed by data related to falls and functioning, and then by data on sleep and activity. Clinicians thought that wearable device data might be especially useful for remotely monitoring patients at high-risk moments in their care trajectory, such as after an acute hospitalization or after starting a new outpatient treatment. Four main themes were discussed by providers in the interviews: (1) corroborating reports, (2) identifying new issues, (3) coordinating care, and (4) patient-provider communication. Although there were no statistically significant differences in clinical recommendations before and after viewing wearable device data for any vignette (all P>.25), all clinicians reported that the wearable device data impacted their decision-making confidence, and most rated the wearable device data as helpful.

CONCLUSIONS: Oncology providers highlighted the potential clinical value of vital sign and physical functioning data from wearable devices, particularly when outpatients might be at risk for readmissions or other acute deteriorations between clinic visits. Providers noted that the objective data captured by consumer wearable devices can be helpful complements to patient and caregiver subjective reports and that this information could improve patient-provider communication and care coordination. During the interviews, most providers found wearable device data to be helpful when making decisions. While there are challenges to address on how to integrate this information into the clinical workflow and communicate alerts with patients, there is cautious enthusiasm among clinicians about how these data could inform and improve cancer care.

PMID:42102279 | DOI:10.2196/86412