Nevin Manimala

JAMA Netw Open. 2026 Apr 1;9(4):e263764. doi: 10.1001/jamanetworkopen.2026.3764.

ABSTRACT

IMPORTANCE: Out-of-hospital cardiac arrest (OHCA) survival is lower in neighborhoods with low (vs high) socioeconomic status. While emergency medical services (EMS) practices of intra-arrest transport (IAT) vary, it is unknown whether neighborhood-level factors are associated with these transport patterns.

OBJECTIVE: To determine the association between greater neighborhood socioeconomic vulnerability and odds of IAT among adults with OHCA.

DESIGN, SETTING, AND PARTICIPANTS: This cohort study used a large national database of deidentified EMS electronic health record data. The cohort comprised US adults (aged ≥18 years) with attempted EMS resuscitations for nontraumatic OHCA between January 1, 2022, and December 31, 2022. Data were analyzed between December 2023 and December 2024.

EXPOSURES: The exposure was the Social Vulnerability Index (SVI) of the EMS encounter within a US Census tract. Neighborhoods were stratified into quartiles based on SVI percentile. Higher SVI percentiles indicated greater socioeconomic vulnerability.

MAIN OUTCOME AND MEASURE: The primary outcome was the odds of IAT. The association between SVI quartile and EMS transport pattern was assessed using marginal logistic regression modeling.

RESULTS: A total of 61 524 patient encounters were included. Patients had a median (IQR) age of 65 (52-76) years and included 38 546 males (62.6%). Bystander resuscitation was administered in 23 124 encounters (37.6%), while 23 492 patients (38.2%) received IAT and 38 032 patients (61.8%) received continued on-scene resuscitation. Adults in neighborhoods in the highest SVI quartile had a higher occurrence of IAT than those in the lowest SVI quartile (7052 [41.1%] vs 4000 [32.8%]; P < .001). After adjustment, patients in the highest SVI quartile had greater odds of receiving IAT than those in the lowest SVI quartile (adjusted odds ratio, 1.35; 95% CI, 1.15-1.57).

CONCLUSIONS AND RELEVANCE: In this cohort study of EMS resuscitations of adults for nontraumatic OHCA, greater neighborhood socioeconomic vulnerability was associated with increased odds of IAT. This association may contribute to socioeconomic disparities in OHCA outcomes and warrant further investigations into factors in EMS transport decisions for OHCA, particularly in marginalized communities.

PMID:41931295 | DOI:10.1001/jamanetworkopen.2026.3764

JAMA Netw Open. 2026 Apr 1;9(4):e264801. doi: 10.1001/jamanetworkopen.2026.4801.

ABSTRACT

IMPORTANCE: Few studies, mostly from the era before the Dobbs v. Jackson Women’s Health Organization US Supreme Court decision, have projected increases in pregnancy-related and maternal mortality in states with restrictive abortion laws. However, the association between post-Dobbs abortion bans and pregnancy-associated mortality remains unclear.

OBJECTIVE: To examine the associations of complete and 6-week abortion bans with pregnancy-associated mortality in the US.

DESIGN, SETTING, AND PARTICIPANTS: This retrospective, population-based cohort study included 14 states with abortion bans and 37 control states, including the District of Columbia, without abortion bans. US National Center for Health Statistics birth and mortality data from 2018 to 2023 were analyzed using synthetic control methods with staggered adoption, comparing ban states to their synthetic controls. Data were analyzed from July to December 2025.

EXPOSURE: State-level implementation of complete or 6-week abortion bans.

MAIN OUTCOMES AND MEASURES: The primary outcome was pregnancy-associated mortality. Secondary outcomes included pregnancy-related, maternal, and nonobstetric causes of death. Mortality ratios were examined quarterly and between preban and postban periods.

RESULTS: From 2018 to 2023, there were 22 011 131 live births and 12 993 pregnancy-associated deaths. Pregnancy-associated mortality declined by 9.8% in nonban states (54.5 [95% CI, 53.3 to 55.8] to 49.2 [95% CI, 46.5 to 52.0] deaths per 100 000 live births). In states with bans, smaller declines were observed: 2.4% in states excluding Texas (83.2 [95% CI, 80.1 to 86.3] to 81.2 [95% CI, 74.5 to 88.4] deaths per 100 000 live births) and 3.3% in Texas (54.2 [95% CI, 50.5 to 58.1] to 52.4 [95% CI, 47.4 to 57.7] deaths per 100 000 live births). Increases were largest among non-Hispanic Asian (41.0%; from 39.5 [95% CI, 27.7 to 54.7] to 55.7 [95% CI, 26.7 to 102.4] deaths per 100 000 live births) and non-Hispanic Black or African American (17.8%; from 140.2 [95% CI, 131.7 to 149.1] to 165.2 [95% CI, 144.2 to 188.3] deaths per 100 000 live births) individuals in ban states excluding Texas. Synthetic control analyses yielded an estimated difference of 5.1 (95% CI, -7.9 to 18.2) pregnancy-associated deaths per 100 000 live births, which was not statistically significant. Overall estimates for pregnancy-related mortality (-2.0; 95% CI, -11.5 to 7.5), maternal mortality (-3.0; 95% CI, -10.2 to 4.2), and nonobstetric causes (1.2; 95% CI, -7.3 to 9.7) were likewise not statistically significant. State-specific estimates were heterogeneous, but none reached statistical significance. Covariate-adjusted models yielded similar results.

CONCLUSIONS AND RELEVANCE: This cohort study found that abortion bans were not associated with statistically significant overall or state-specific increases in pregnancy-associated mortality. The short postban observation window and wide CIs highlight the need for continued surveillance as more post-Dobbs data become available.

PMID:41931294 | DOI:10.1001/jamanetworkopen.2026.4801

JAMA Netw Open. 2026 Apr 1;9(4):e264812. doi: 10.1001/jamanetworkopen.2026.4812.

ABSTRACT

IMPORTANCE: The Salton Sea, a drying saline lake in southeastern California, is a growing source of wind-blown dust. Its long-term impact on children’s lung function growth remains unclear.

OBJECTIVE: To investigate the association of proximity to the Salton Sea and dust exposure with children’s lung function growth trajectories.

DESIGN, SETTING, AND PARTICIPANTS: For this longitudinal cohort study, community-engaged research was conducted in Imperial Valley, California, in partnership with Comité Civico del Valle, a long-standing local community organization. Children in first to third grades from 5 elementary schools near the Salton Sea were invited to participate between May 1, 2017, and May 27, 2019. Participants with missing data on core variables or with only 1 spirometry measure were excluded from analysis. Lung function assessment was conducted from March 22, 2019, to July 25, 2022; data analyses were conducted from July 2024 to July 2025.

EXPOSURES: The primary exposure was the distance from each child’s home to the edge of the Salton Sea, with residence near the sea defined as less than 11 km. Secondary exposures included particulate matter (PM) and dust storm hours (PM10 > 150 µg/m3), estimated using data from regulatory monitors.

MAIN OUTCOMES AND MEASURES: Lung function was assessed via spirometry (forced expiratory volume in 1 second [FEV1] and forced vital capacity [FVC]). Covariates included age, sex, ethnicity, socioeconomic status, height, body mass index, baseline respiratory health, and asthma status.

RESULTS: Of 499 children enrolled, 369 were included in the final analysis (205 [55.6%] female and 164 [44.4%] male), with a mean (SD) baseline age of 10.1 (0.6) years and mean (SD) follow-up of 2.0 (1.0) years, contributing a total of 1146 spirometry measurements (approximately 3 per participant). In fully adjusted mixed effects models, living near the sea (<11 km) was associated with 52.18 mL/y lower FVC growth (95% CI, -100.96 to -3.40 mL/y; P = .04), compared with living farther from the sea. The association with FEV1 did not reach statistical significance. More hours of dust event exposure were associated with lower FVC (β = -4.10 mL/y; 95% CI, -7.55 to -0.75 mL/y) and FEV1 growth (β = -2.26 mL/y; 95% CI, -4.22 to -0.29 mL/y), with a stronger association between dust event and FVC observed among children living near the sea (P for interaction = .04).

CONCLUSIONS AND RELEVANCE: In this cohort study of school-aged children, closer residential proximity to the Salton Sea was associated with reduced lung function growth. These findings underscore the need to address environmental degradation in the region to protect children’s respiratory health.

PMID:41931293 | DOI:10.1001/jamanetworkopen.2026.4812

JAMA Netw Open. 2026 Apr 1;9(4):e264864. doi: 10.1001/jamanetworkopen.2026.4864.

ABSTRACT

IMPORTANCE: Rural-urban differences in health outcomes have worsened over time, yet the variation in exposure to social determinants of health (SDOH), which are key drivers of these outcomes, has not been adequately quantified.

OBJECTIVE: To explore variation in exposure to a sample of beneficial and adverse community-level SDOH across the rural-urban continuum.

DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study included all residential addresses in Maryland using GPS-Health (Geographic Patterns of SDOH), a 2025 statewide address-level dataset.

MAIN OUTCOMES AND MEASURES: The straight-line (great-arc) distance to the nearest resource (hospital, federally qualified health center [FQHC], pharmacy, Supplemental Nutrition Assistance Program [SNAP] retailer, civic center, and major roadway) or hazard (gun violence incident, eviction site, and Environmental Protection Agency [EPA]-designated site) was estimated. Addresses were categorized using Rural-Urban Commuting Area codes as urban (1-3), large rural (4-6), small rural (7-9), and isolated rural (10). Linear mixed-effects models estimated adjusted differences by rurality.

RESULTS: The study included 2 070 970 addresses: 1 933 793 urban addresses (93.4%), 86 270 large-rural addresses (4.2%), 17 594 small-rural addresses (0.8%), and 33 313 isolated-rural addresses (1.6%). Adults aged 65 years and older were most prevalent in large-rural areas (30.8%), disability was more prevalent in small-rural areas (17.9%), and both were more common in isolated-rural than urban areas (older adults: 27.7% vs 17.1%; disability: 15.6% vs 11.6%). Compared with urban addresses in an adjusted model, isolated-rural addresses were farther from hospitals (estimated difference, 4.22 [95% CI, 3.32 to 5.13] miles), pharmacies (estimated difference, 2.16 [95% CI, 1.54 to 2.80] miles), SNAP retailers (estimated difference, 1.15 [95% CI, 0.83 to 1.47] miles), and civic centers (estimated difference, 1.09 [95% CI, 0.67 to 1.50] miles). FQHCs were closest to large-rural addresses (estimated difference, -2.13 [95% CI, -2.50 to -1.76] miles). Urban addresses were closest to hazards.

CONCLUSIONS AND RELEVANCE: In this cross-sectional study of all residential addresses in Maryland, distance from health-promoting resources increased with rurality, with isolated-rural areas farthest, despite a higher representation of populations with greater health care needs. Our findings support examining rurality as a continuum rather than a dichotomy to better characterize health outcomes and SDOH variation and to inform place-specific interventions.

PMID:41931292 | DOI:10.1001/jamanetworkopen.2026.4864

JAMA Netw Open. 2026 Apr 1;9(4):e265009. doi: 10.1001/jamanetworkopen.2026.5009.

ABSTRACT

IMPORTANCE: Disparities in outcomes for emergency general surgery (EGS) procedures may reflect structural inequities in access and care. Understanding how social and economic determinants contribute to these disparities could help identify opportunities to reduce them.

OBJECTIVE: To assess racial disparities between: (1) surgical setting (elective vs EGS), (2) surgical modality (minimally invasive [MIS] vs open), and (3) clinical outcomes of EGS procedures stratified by modality.

DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study using data from Premier Healthcare Database, a national, all-payer hospital discharge dataset, spanning 2016 to 2022. Participants were non-Hispanic Black or non-Hispanic White adult patients undergoing cholecystectomy, inguinal hernia repair, ventral hernia repair, or colorectal resections. Data analysis was performed from March 2025 to February 2026.

EXPOSURE: Surgical setting (elective vs EGS) and surgical modality (MIS vs open).

MAIN OUTCOMES AND MEASURES: The primary outcome was operative setting and modality, analyzed with multivariable logistic regression. Secondary outcomes included length of stay, perioperative complications, 30-day readmission, conversion to open modality, and in-hospital mortality. Propensity score matching was used to compare clinical outcomes between Black and White patients undergoing EGS by surgical modality.

RESULTS: Among 2 443 304 procedures, 254 281 (10.4%) were performed on Black patients, 2 189 023 (89.5%) were performed on White patients, 1 231 252 (50.3%) were performed on female patients, and 788 205 (32.3%) were performed emergently. Most patients were aged 45 to 64 years (939 123 patients [38.4%]). Black patients had higher adjusted odds of undergoing emergency vs elective procedures (adjusted odds ratio [aOR], 1.29; 95% CI, 1.28-1.30) and open vs MIS in the emergency setting (aOR, 1.06; 95% CI, 1.03-1.08) compared with White patients. Patients undergoing EGS were more likely to be older, female, Black, publicly insured, have higher comorbidity, live in rural areas, and be treated at nonteaching hospitals. Among MIS procedures, Black patients had higher rates of 30-day readmission, longer lengths of stay, and higher conversion to open surgery. For open surgical procedures, Black patients had longer lengths of stay.

CONCLUSIONS AND RELEVANCE: In this retrospective cohort study, Black patients faced disparities in surgical setting, access to MIS, and outcomes. These inequities highlight the need for targeted, equity-focused interventions to expand access to MIS and improve outcomes across diverse populations.

PMID:41931291 | DOI:10.1001/jamanetworkopen.2026.5009

JAMA Health Forum. 2026 Apr 3;7(4):e260414. doi: 10.1001/jamahealthforum.2026.0414.

ABSTRACT

IMPORTANCE: Amid an ongoing addiction crisis, private equity (PE) firms have acquired large numbers of residential substance use disorder (SUD) treatment facilities in the US. How PE ownership affects SUD care prices and facility characteristics is not well understood.

OBJECTIVE: To evaluate prices and facility characteristics of residential substance use treatment facilities owned by PE firms compared with other for-profit facilities.

DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study using a secret shopper framework was conducted from June 2024 to April 2025. PE-acquired residential SUD treatment facilities were matched to non-PE-acquired, for-profit control facilities by geographic proximity. Trained callers posed as individuals seeking residential SUD care for a family member with pending Medicaid insurance.

EXPOSURES: Ownership by PE vs non-PE for-profit entities.

MAIN OUTCOMES AND MEASURES: The primary outcome was daily rate. Secondary outcomes included bed availability and wait times, admission requirements, services, staffing, amenities, and facility-initiated contact.

RESULTS: This study included 341 residential facilities with completed call data (127 PE-acquired, 214 geographically matched non-PE for-profit). Mean (SD) daily rates were 15.6% higher at PE facilities ($910.73 [$463.16]; median, $854.29 [IQR, $589.29-$1071.43]) compared with non-PE facilities ($779.87 [$501.92]; median, $750.56 [IQR, $480.64-$952.38]; Benjamini-Hochberg-adjusted P = .04). This significantly higher daily rate was also found after adjustment for geographic cluster-matched fixed effects (β = $127.73; 95% CI, $29.57-$225.87; adjusted P = .03). Compared with non-PE-acquired control facilities, PE-acquired facilities were less likely to offer detox services (74.8% vs 88.8%; adjusted P = .02) and private rooms (12.1% vs 25.7%; adjusted P = .02), and more likely to make postcall contact attempts (mean [SD], 0.68 [1.39] vs 0.18 [0.47]; adjusted P < .001).

CONCLUSIONS AND RELEVANCE: In this national secret shopper study, PE-acquired residential SUD treatment facilities reported higher daily prices than geographically matched non-PE for-profit facilities. Price differences persisted after accounting for local market factors, suggesting systematic cost differences associated with ownership structure. This study provides facility-level evidence on pricing differences by ownership type in residential SUD treatment and highlights the need for further research to understand the mechanisms underlying these differences and their implications for patients and payers.

PMID:41931287 | DOI:10.1001/jamahealthforum.2026.0414

JAMA Health Forum. 2026 Apr 3;7(4):e260491. doi: 10.1001/jamahealthforum.2026.0491.

ABSTRACT

IMPORTANCE: Variation in cardiovascular care completion is well documented. However, less is known about differences originating from earlier, intermediate stages such as ordering or scheduling of testing or referrals, despite their role as key prerequisites for care access.

OBJECTIVE: To examine the care cascades for coronary artery disease (CAD) after emergency department (ED) visits and to identify the specific stages at which variation emerges for CAD testing and cardiology referrals.

DESIGN, SETTING, AND PARTICIPANTS: This was a retrospective cohort study using data and metadata from electronic health records from a large multicenter health system. Participants were adult patients with established primary care and no history of ischemic heart disease or cardiology care who presented to an ED from January 1, 2020, to June 30, 2022, and underwent a troponin test, a proxy for clinically suspected myocardial ischemia. Variation in cardiovascular follow-up care (CAD testing and cardiology referrals) was identified and analyzed. Analyses were restricted to patients with above-median electrocardiogram (ECG)-derived ischemia risk scores to enrich for higher likelihood of benefit from cardiovascular follow-up.

MAIN OUTCOMES AND MEASURES: Receipt of an order for CAD testing (stress tests, coronary computed tomography angiography) or cardiology referral, scheduling of the service, and completion within 6 months. Outcomes were compared by insurance type, race and ethnicity, language, and sex using multivariable logistic regression adjusted for demographic characteristics, clinical factors, and ECG-derived cardiovascular risk.

RESULTS: Among 16 475 patients with an ED visit (median [IQR] age, 67.4 [54.9-77.9] years; 36% female and 64% male individuals) and elevated cardiovascular risk, marked variation in follow-up care emerged. Compared to commercially insured patients, those with Medicare dual or disabled coverage had lower adjusted odds of completing CAD testing (adjusted odds ratio [aOR], 0.45; 95% CI, 0.36-0.56) and cardiology referrals (aOR, 0.47; 95% CI, 0.39-0.57); similar patterns were seen for Medicaid coverage. Patients whose primary language was not English were less likely to complete either service (CAD testing aOR, 0.77; 95% CI, 0.61-0.98; referral aOR, 0.75, 95% CI, 0.61-0.92), and female patients had lower adjusted odds of completing CAD testing (aOR, 0.86; 95% CI, 0.77- 0.96). Adjusted differences by race and ethnicity were modest. Variation was primarily associated with ordering differences and with additional scheduling barriers for select groups. Once scheduled, completion rates exceeded 75%, without differences between groups.

CONCLUSIONS AND RELEVANCE: This retrospective cohort study found that among patients who visited the ED with elevated ischemic risk, attrition in follow-up care was concentrated early in care cascades and most pronounced among those with noncommercial health insurance. This stepwise analytic framework offers a novel, reproducible approach for health systems to identify where and for whom care gaps arise, which can enable targeted interventions to improve equity and efficiency.

PMID:41931286 | DOI:10.1001/jamahealthforum.2026.0491

Brain Inform. 2026 Apr 3. doi: 10.1186/s40708-026-00299-w. Online ahead of print.

ABSTRACT

PURPOSE: MELD Graph is a state-of-the-art artificial intelligence (AI) model for automated detection of focal cortical dysplasia (FCD), but its performance remains limited, highlighting the need to investigate which aspects of the pipeline affect its accuracy.

METHODS: A retrospective failure-mode analysis of the MELD Graph pipeline was performed in 242 subjects, with model predictions and FreeSurfer segmentations reviewed to classify errors as segmentation-associated or algorithm-related. FCD imaging features salient to humans were quantified, with statistical associations examined for both MELD Graph detection and focal FreeSurfer segmentation failure.

RESULTS: MELD Graph demonstrated overall performance similar to previously published non-harmonized results, achieving a sensitivity of 69%, specificity of 44%, and positive predictive value (PPV) of 75%. Focal FreeSurfer segmentation failures were associated with 21% of false negative patients, 25% of false positive clusters in patients, and 16% of false positive clusters in controls. Following manual cortical segmentation correction and rerunning of MELD Graph, 67% of the segmentation-associated missed lesions were detected, and segmentation-associated false positive clusters were reduced or eliminated in 75% of controls with such clusters. Higher conspicuity on T1-weighted images was associated with MELD Graph detection, whereas greater conspicuity on T2-FLAIR images relative to T1 was associated with detection failure. Non-bottom-of-sulcus lesion location, higher human conspicuity measures, and low T1 image quality were positively associated with focal FreeSurfer segmentation failures.

CONCLUSION: FreeSurfer segmentation failures are a significant potential source of error in the MELD Graph pipeline. FCD imaging features salient to humans and image quality were also associated with variability in algorithm performance. Robust cortical segmentation and stronger integration of T2-FLAIR imaging features may be beneficial for automated FCD detection tools.

CLINICAL TRIAL REGISTRATION: Not applicable. This study is a retrospective analysis of previously acquired open-source imaging datasets and does not constitute a clinical trial.

PMID:41931246 | DOI:10.1186/s40708-026-00299-w

Drugs R D. 2026 Apr 3. doi: 10.1007/s40268-026-00543-y. Online ahead of print.

ABSTRACT

BACKGROUND AND OBJECTIVES: Viloxazine, which has been used to treat depression and attention-deficit/hyperactivity disorder (ADHD), has been termed a moderate-affinity, selective norepinephrine reuptake inhibitor based on high selectivity for norepinephrine relative to serotonin and dopamine transporters. However, accumulated research suggests a more complex mechanism of action, based on studies showing activity at serotonin 5-HT_2C, 5-HT_2B, and 5-HT₇ receptors, as well as findings that viloxazine increases extracellular serotonin (along with norepinephrine and dopamine) in the rat prefrontal cortex. This in vitro pharmacology study aimed to replicate and expand prior experiments to better characterize viloxazine’s affinity for and activity at the norepinephrine transporter (NET) and individual serotonin receptors and to clarify how these effects contribute to the mechanism of action.

METHODS: Using in vitro binding competition and functional assays and ex vivo receptor occupancy studies in rats, we assessed viloxazine activity at human NET isoforms and 5-HT_2C, 5-HT_2B, and 5-HT₇ receptors relative to clinically relevant unbound viloxazine plasma concentrations (0.4-3.6 μM).

RESULTS: Viloxazine showed moderate binding affinity for NET (inhibition constant [K_i] = 0.13 µM) and 5-HT_2C (K_i = 0.66 µM), 5-HT_2B (K_i = 0.83 µM), and 5-HT₇ (K_i = 1.90 µM) receptors. In vitro functional studies showed viloxazine acted as a NET inhibitor, 5-HT_2C partial agonist, and 5-HT_2B and 5-HT₇ antagonist. At clinically relevant concentrations, viloxazine could potentially occupy nearly 95% of NET, more than 80% of 5-HT_2C and 5-HT_2B, and 65% of 5-HT₇ receptors. Subsequent ex vivo studies in rats confirmed high NET occupancy (67-94%) at clinically relevant concentrations.

CONCLUSIONS: These results validate previous experiments showing that viloxazine, in addition to displaying high NET occupancy, acts as a partial agonist at 5-HT_2C receptors and an antagonist at 5-HT_2B and 5-HT₇ receptors at clinically relevant concentrations for ADHD treatment. Therefore, both NET inhibition and serotonin receptor activity may contribute to viloxazine’s clinical efficacy. These findings are contributing to a renewed understanding of viloxazine’s pharmacodynamic profile and likely multimodal mechanism of action.

PMID:41931242 | DOI:10.1007/s40268-026-00543-y

Trop Anim Health Prod. 2026 Apr 3;58(3):217. doi: 10.1007/s11250-026-05018-5.

NO ABSTRACT

PMID:41931203 | DOI:10.1007/s11250-026-05018-5