Nevin Manimala

Brain Spine. 2026 Jul 1;6:106157. doi: 10.1016/j.bas.2026.106157. eCollection 2026.

ABSTRACT

INTRODUCTION: Treatment-refractory chronic pain is a prevalent condition affecting a significant portion of the population. Available treatment strategies range from non-invasive to invasive approaches, including several surgical procedures. The most commonly reported intracranial neurosurgical interventions are deep brain stimulation (DBS) and ablative techniques such as cingulotomy, thalamotomy, and mesencephalotomy.

RESEARCH QUESTION: This study aimed to evaluate the efficacy of different intracranial surgical treatments for refractory chronic pain through a systematic review and meta-analysis, focusing on quantitative trends in clinical pain outcomes.

MATERIAL AND METHODS: A systematic literature search was conducted in PubMed according to PRISMA guidelines.

RESULTS: In total, 75 studies including 666 patients that underwent at least one surgical procedure, with nearly half achieving significant pain reduction (>50%). A meta-analysis compared surgical treatments; where mesencephalotomy was excluded due to insufficient data. Pain levels at baseline were compared at four follow-up periods: T1 (≤1 month), T2 (>1-≤6 months), T3 (>6-≤12 months), and T4 (>12 months). Wilcoxon tests demonstrated statistically significant differences between baseline and the latest follow-up for all included methods: DBS: p < 0.001, g = 1.44 85-90%; cingulotomy: p < 0.001, g = 2.6 > 95%; thalamotomy: p < 0.001, g = 0.92 ≈ 74%. Comparisons between follow-up time points were possible only for DBS, which also showed significant differences (p < 0.05).

DISCUSSION AND CONCLUSION: Our findings indicate that intracranial surgical procedures for chronic pain are effective/safe and may maintain their clinical benefit for months following treatment. Furthermore, substantial variability in clinical outcomes was observed, even after stratification according to etiology and target groups.

PMID:42472183 | PMC:PMC13380498 | DOI:10.1016/j.bas.2026.106157

Cureus. 2026 Jun 18;18(6):e111081. doi: 10.7759/cureus.111081. eCollection 2026 Jun.

ABSTRACT

Background Hormone Replacement Therapy (HRT) is a widely used method for endometrial preparation in Frozen Embryo Transfer (FET) cycles. Although multiple estradiol formulations and routes of administration exist, limited data directly compare oral estradiol hemihydrate, vaginal estradiol hemihydrate, and oral estradiol valerate. This study evaluated the efficacy and safety of these three estradiol regimens for endometrial preparation in an assisted reproduction setting. Objectives To compare endometrial outcomes, serum estradiol levels, and pregnancy outcomes among three estradiol treatment protocols, oral estradiol hemihydrate, vaginal estradiol hemihydrate, and oral estradiol valerate, in HRT‑based FET cycles. Methods This prospective, open‑label, three‑arm investigator‑initiated study was conducted at a single center and included 133 women aged 25-42 years undergoing HRT‑FET cycles. Participants received one of the following regimens: oral estradiol hemihydrate, vaginal estradiol hemihydrate, or oral estradiol valerate. Endometrial thickness, endometrial volume, and serum estradiol levels on progesterone‑start day were measured. Clinical outcomes included serum β-human chorionic gonadotropin (β‑hCG) positivity and clinical pregnancy rates. Data were analyzed using descriptive and comparative statistics. Results The mean daily estradiol dose was significantly lower with vaginal estradiol hemihydrate compared to both oral arms (p<0.001). Endometrial thickness and volume showed no significant differences among groups. Mean serum estradiol levels were highest with vaginal estradiol hemihydrate (701.63 pg/mL), significantly exceeding levels with oral estradiol hemihydrate (331.84 pg/mL; p=0.042). Serum β‑hCG positivity rates were 58.33%, 47.62%, and 40.47% (p=0.375) and clinical pregnancy rates were comparable at 44.0%, 28.0%, and 22.7% (p=0.168) in oral estradiol hemihydrate, vaginal estradiol hemihydrate, and oral estradiol valerate groups, respectively. Conclusions Estradiol hemihydrate, whether administered orally or vaginally, demonstrated non‑inferior efficacy to oral estradiol valerate for endometrial preparation in FET cycles. Vaginal estradiol hemihydrate achieved adequate endometrial development at significantly lower doses overcoming the barriers of first pass metabolism and minimizing the safety concerns of thrombo-embolism.

PMID:42472174 | PMC:PMC13380402 | DOI:10.7759/cureus.111081

Cureus. 2026 Jun 18;18(6):e111083. doi: 10.7759/cureus.111083. eCollection 2026 Jun.

ABSTRACT

Background Medicare direct graduate medical education (DGME) payments are essential to sustaining residency training and shaping the physician workforce. While geographic variation in total DGME spending is well described, less is known about inequities in per-resident funding across states and program sizes. Objective The objective of this article was to assess variation in Medicare DGME payments per resident across US states and residency program sizes and identify patterns relevant to equitable graduate medical education (GME) funding. Methods In 2025, we conducted a retrospective cross-sectional analysis of publicly available Medicare DGME payment data from 2014-2024. All US hospitals reporting DGME payments were eligible (N = 447), with 439 hospitals included (98.2%). Hospitals were stratified by state and residency program size: small (0-20 residents), mid-sized (21-200), and large (>200). The primary outcome was DGME payment per resident. Comparisons were performed across states and program sizes. Sensitivity analyses evaluated resident count and hospital bed capacity. Results Per-resident DGME payments varied significantly by state and program size (p<0.001). The national median payment was approximately $22,000 per resident, with the highest payments in Mississippi and the lowest in California. Small programs received higher mean per-resident payments than mid-sized programs (p<0.01). Hospitals in the highest and lowest payment deciles were concentrated within specific states. Resident count was a stronger predictor of per-resident payments than hospital bed capacity (p<0.001). Conclusions Substantial geographic and program-size-related inequities in per-resident DGME funding persist nationwide. This may disadvantage mid-sized and underserved programs and should be considered in promoting equitable training and workforce distribution.

PMID:42472170 | PMC:PMC13380125 | DOI:10.7759/cureus.111083

Cureus. 2026 Jun 18;18(6):e111112. doi: 10.7759/cureus.111112. eCollection 2026 Jun.

ABSTRACT

BACKGROUND: Peripheral arterial disease (PAD) is a major global health concern, as critical limb-threatening ischemia leads to higher rates of amputation and mortality. The prognostic impact of prior minor amputation (PMA) is unclear. This study compares major amputation and all-cause mortality rates in patients with PAD with and without PMA and examines key demographic and clinical differences between these groups.

METHODS: This retrospective cohort study included 430 consecutive patients with PAD at a tertiary vascular center. Patients were stratified according to PMA status into a PMA group (n = 72, 16.7%) and a non-PMA group (n = 358, 83.3%). Demographic data, comorbidities, and treatments were analyzed. Primary outcomes were major amputation and all-cause mortality. Statistical analysis included unpaired t-tests, chi-square tests, Cox proportional hazards regression, and Kaplan-Meier analysis.

RESULTS: Among 430 patients, 72 (16.7%) had PMA, whereas 358 (83.3%) did not. The PMA group had higher rates of smoking (n = 45, 62.5%, vs. n = 175, 48.9%; P = 0.039), chronic kidney disease (n = 29, 40.3%, vs. n = 98, 27.4%; P = 0.034), and revascularization (n = 16, 22.2%, vs. n = 14, 3.9%; P < 0.001), but lower utilization of antiplatelet therapy (n = 34, 47.2%, vs. n = 229, 64.0%; P = 0.006) and statin therapy (n = 38, 52.8%, vs. n = 258, 72.1%; P = 0.001). Although unadjusted Kaplan-Meier analysis demonstrated lower survival in the PMA group, multivariable Cox regression showed that PMA was associated with a lower adjusted risk of major amputation (hazard ratio (HR), 0.05; 95% confidence interval (CI), 0.02-0.18; P = 0.001) and all-cause mortality (HR, 0.44; 95% CI, 0.22-0.87; P = 0.017). Statin therapy (HR, 0.21; 95% CI, 0.10-0.43; P < 0.001) and anticoagulation (HR, 0.39; 95% CI, 0.21-0.72; P = 0.003) were associated with reduced mortality risk, whereas revascularization was associated with increased mortality risk (HR, 2.02; 95% CI, 1.05-3.83; P = 0.033).

CONCLUSIONS: PMA was associated with lower adjusted risks of major amputation and mortality in this retrospective cohort of patients with PAD. These results represent observational associations and require prospective validation. Aggressive medical management should be prioritized in all patients with PAD.

PMID:42472145 | PMC:PMC13380416 | DOI:10.7759/cureus.111112

Cureus. 2026 Jun 17;18(6):e111064. doi: 10.7759/cureus.111064. eCollection 2026 Jun.

ABSTRACT

Introduction Breast self-examination (BSE) is promoted as a component of breast self-awareness and a preventive measure, yet its psychosocial impact remains debated. This study aimed to evaluate the effects of BSE education on self-efficacy, health anxiety, and health locus of control among Greek women. Materials and methods A prospective cohort of 298 women (mean age 48.7 ± 10.7 years) participated in a structured BSE educational intervention. Psychosocial parameters were assessed at baseline, 6, and 12 months using validated scales: general self-efficacy, health anxiety, and multidimensional health locus of control. Statistical analyses included repeated-measures ANOVA, post hoc comparisons, and regression modeling to explore temporal changes and predictors. Results BSE practice increased markedly from 44.3% (n = 132) at baseline to 92.2% (n = 271) at six months and 85.0% (n = 250) at 12 months (Cochran’s Q = 188.96, p < 0.001). Self-efficacy and health anxiety scores remained stable over time (p = 0.570 and p = 0.955, respectively). Health locus of control subscales revealed small but statistically significant declines in internal control (baseline: 19.2 ± 4.9; 12 months: 18.1 ± 4.6; p < 0.001) and in attribution to “powerful others” and “chance” (p = 0.040 and p = 0.039). Regression analyses indicated that prior scores were the strongest predictors of 12-month outcomes, with age associated with greater reliance on “powerful others” (β = 0.107, p = 0.040). No increase in health anxiety was observed despite the rise in BSE practice. Conclusions BSE education significantly enhanced preventive behavior without increasing health anxiety or altering general self-efficacy. These findings support BSE education as a complementary strategy for breast health awareness, emphasizing its role in early care-seeking rather than as a substitute for formal screening.

PMID:42472144 | PMC:PMC13379682 | DOI:10.7759/cureus.111064

Cureus. 2026 Jun 18;18(6):e111073. doi: 10.7759/cureus.111073. eCollection 2026 Jun.

ABSTRACT

INTRODUCTION: Cuffed tunneled hemodialysis catheters are an important vascular access option for patients with end-stage renal disease (ESRD) when arteriovenous fistula (AVF) creation is not feasible or when urgent initiation of hemodialysis is required. However, clinical outcomes may vary according to the catheter insertion site.

OBJECTIVE: To compare procedural safety, biochemical outcomes, and six-month clinical outcomes among different tunneled hemodialysis catheter insertion sites.

METHODS: This retrospective observational study included 1,050 consecutive patients who underwent tunneled hemodialysis catheter insertion over four years at a tertiary care center. Patients were categorized according to catheter insertion site into right internal jugular vein (RIJV; n = 535), left internal jugular vein (LIJV; n = 416), subclavian vein (n = 53), and femoral vein (n = 46) groups. Baseline characteristics, procedure-related complications, laboratory outcomes at three months, and clinical outcomes at six months were compared using appropriate statistical analyses.

RESULTS: Baseline demographic and laboratory characteristics were comparable among all groups (all P > 0.05). Procedure-related complications were significantly more frequent in the subclavian and femoral groups, including exit-site bleeding (P = 0.032), catheter malposition (P = 0.028), hematoma formation (P = 0.018), arterial puncture (P = 0.022), hypoxia (P = 0.036), arrhythmia (P = 0.041), and pneumothorax (P = 0.048). At three months, patients with subclavian and femoral access demonstrated significantly poorer biochemical profiles, characterized by lower hemoglobin and serum albumin levels and higher leukocyte counts, serum creatinine, C-reactive protein, phosphorus, and intact parathyroid hormone levels (all p<0.05). At six months, internal jugular vein access was associated with significantly higher rates of successful AVF creation (P = 0.018) and ongoing catheter survival (P = 0.012). Conversely, subclavian and femoral access were associated with significantly higher rates of catheter dysfunction (P = 0.015), catheter-related bloodstream infection (P = 0.013), and mortality (P = 0.020).

CONCLUSIONS: Internal jugular vein access, particularly RIJV access, was associated with superior procedural safety, more favorable biochemical profiles, and better six-month clinical outcomes compared with subclavian and femoral access. These findings support the preferential use of internal jugular vein access for tunneled hemodialysis catheter placement whenever feasible.

PMID:42472140 | PMC:PMC13379867 | DOI:10.7759/cureus.111073

Cureus. 2026 Jun 18;18(6):e111067. doi: 10.7759/cureus.111067. eCollection 2026 Jun.

ABSTRACT

Background Sinonasal malignancies are uncommon head and neck tumors that frequently present at an advanced stage due to their deep anatomical location and nonspecific early symptoms. Orbital involvement represents an important indicator of locally aggressive disease and has direct implications for staging and treatment planning. This study was conducted to analyze the clinicopathological profile, radiological patterns of orbital invasion, and management strategies in patients with sinonasal malignancies involving the orbit. Methods A retrospective observational study was carried out in the Department of ENT – Head and Neck Surgery at the Pakistan Institute of Medical Sciences, Islamabad, Pakistan. Patients with histopathologically confirmed sinonasal malignancies and radiological evidence of orbital extension from April 2022 to March 2026 were included. Relevant demographic, histological, staging, orbital invasion patterns, treatment modalities, and discharge outcomes were extracted from hospital records. Data were analyzed using descriptive statistics, and associations were assessed using chi-square and Fisher’s exact tests where appropriate. Results A total of 78 patients were included. The mean age was 57.6 ± 12.2 years, and 45 (57.69%) were male. Squamous cell carcinoma was the most common histological subtype (28, 35.90%), followed by adenocarcinoma (18, 23.08%) and sinonasal undifferentiated carcinoma (13, 16.67%). All patients presented with advanced disease, including 16 (20.51%) at stage III and 62 (79.49%) at stage IV. Eye-related clinical features were common, with ocular pain/discomfort in 56 (71.79%), proptosis in 48 (61.54%), and epiphora in 44 (56.41%) patients. A significant difference in mean age was observed across histological subtypes (p = 0.003), while no significant associations were found with gender (p = 0.92), stage (p = 0.41), or pattern of orbital invasion (p = 0.95). The highest level of erosion seen on radiology showed that only lamina papyracea erosion was the most frequent orbital involvement (31, 39.74%), followed by periorbital tissue (18, 23.08%), extraconal fat (13, 16.67%), extraocular muscles (10, 12.82%), and orbital apex (6, 7.69%). Orbit-preserving surgery was performed in 53 (67.95%) patients, while 16 (20.51%) underwent exenteration and 9 (11.54%) received chemoradiotherapy. A significant association was noted between histological subtype and surgical management (p < 0.001), with higher exenteration rates in sinonasal undifferentiated carcinoma and adenoid cystic carcinoma. Conclusion Sinonasal malignancies with orbital involvement most commonly presented at an advanced stage (predominantly stage IV), with squamous cell carcinoma being the most frequent histological subtype and the lamina papyracea being the commonest route of orbital extension. A significant variation in mean age was observed across histological subtypes, whereas no significant association was found between histology and gender, stage, pattern of orbital invasion, or overall treatment modality. However, histological subtype showed a significant association with surgical management, particularly the need for orbital exenteration.

PMID:42472132 | PMC:PMC13379717 | DOI:10.7759/cureus.111067

Sleep Adv. 2026 Jun 22;7(3):zpag067. doi: 10.1093/sleepadvances/zpag067. eCollection 2026.

ABSTRACT

Operational environments such as naval vessels demand sustained coordination and precision under conditions that test both physical and psychological endurance. This study examined associations among fatigue-related factors, perceived social support, occupational context, and perceived team functioning among 26 438 active-duty US Navy personnel. Measures included self-reported sleep needed, sleep opportunity, and sleep obtained, which were used to calculate sleep deficit and sleep opportunity conversion, along with self-reported sleep disturbance, fatigue impairment (FI), perceived social support, and perceived team processes. Hierarchical regression analyses showed that FI was strongly associated with lower perceived team functioning (β = -0.35; 95% confidence interval [CI], -0.37 to -0.33; p < .001). Social support was positively associated with perceived team functioning (β = 0.31; 95% CI, 0.29 to 0.33; p < .001) and statistically attenuated the negative association between FI and perceived team functioning (β = 0.07; 95% CI, 0.05 to 0.09; p < .001). Quadratic analyses indicated that associations between fatigue-related factors and perceived team functioning were stronger at moderate-to-high levels of FI and calculated sleep deficit. Occupational rate accounted for additional contextual variance, with mechanical and deck rates reporting higher FI and lower perceived team functioning than administrative or medical rates. As all constructs were assessed using cross-sectional, single-source self-report data, findings should be interpreted as correlational associations with perceived team processes rather than objective performance effects or causal impacts of insufficient sleep.

PMID:42472125 | PMC:PMC13380305 | DOI:10.1093/sleepadvances/zpag067

Clin Cosmet Investig Dermatol. 2026 Jul 14;19:615985. doi: 10.2147/CCID.S615985. eCollection 2026.

ABSTRACT

PURPOSE: Hypertrophic scars (HS), common fibroproliferative disorders, predominantly affect younger individuals. To investigate potential causal associations between multiple genetically proxied biological aging indicators and the risk of HS using a two-sample Mendelian randomization (MR) approach.

PATIENTS AND METHODS: We used genome-wide association studies (GWAS) data to examine causal links between biological aging indicators (epigenetic clocks, telomere length, macroscopic aging) and HS. Primary analysis employed inverse-variance weighted MR, with sensitivity analyses (MR-Egger, weighted median, weighted mode) and multivariable MR adjusting for fibrogenic mediators. Results were validated in independent cohorts. Robustness was assessed via MR-PRESSO, Cochran’s Q, MR-Steiger, and leave-one-out analyses to detect statistical evidence of directional and horizontal pleiotropy.

RESULTS: Genetically predicted higher IEAA (Odds Ratio [OR]=0.926, 95% Confidence Interval [CI]: 0.878-0.976, P=0.004) and higher PhenoAge (OR=0.911, 95% CI: 0.848-0.979, P=0.011) were nominally associated with a decreased risk of HS. The PhenoAge association was consistently replicated in the independent validation cohort (OR=0.91, P=0.0059). However, these associations did not remain significant after False Discovery Rate correction. Negative control analysis showed no association with general skin fibrosis, suggesting specificity for hyper-proliferative scarring. Multivariable MR indicated that the protective effect of PhenoAge was independent of classical fibrogenic pathways. No significant causal associations were found for other aging indicators. No statistical evidence of directional or horizontal pleiotropy was detected in sensitivity analyses.

CONCLUSION: This MR study provides exploratory evidence suggesting that genetically proxied faster epigenetic aging may be nominally associated with a reduced risk of HS. These findings offer novel hypotheses regarding the complex interplay between aging processes and scar formation.

PMID:42472084 | PMC:PMC13380249 | DOI:10.2147/CCID.S615985

Drug Des Devel Ther. 2026 Jul 14;20:625824. doi: 10.2147/DDDT.S625824. eCollection 2026.

ABSTRACT

PURPOSE: To compare the efficacy and safety of dexamethasone alone versus dexamethasone combined with droperidol for the prevention of postoperative nausea and vomiting (PONV) in patients undergoing gynecological day surgery under ciprofol-alfentanil general anesthesia.

PATIENTS AND METHODS: A total of 268 patients scheduled for gynecological day surgery were randomly assigned to the DD group (dexamethasone-droperidol, n=134) or the DN group (dexamethasone-normal saline, n=134). Before induction of anesthesia, the DD group received 5 mg dexamethasone plus 1 mg droperidol, while the DN group received 5 mg dexamethasone plus normal saline. Anesthesia induction: ciprofol 0.5 mg/kg, alfentanil 20 μg/(kg·h), and mivacurium 0.2 mg/kg. Anesthesia maintenance: ciprofol 1.25 mg/(kg·h), alfentanil 40 μg/(kg·h), with bispectral index (BIS) maintained at 40-60. The primary outcome was the incidence of PONV within 24 h postoperatively. Secondary outcomes included the incidence of adverse events within 24 h postoperatively, patient satisfaction, hemodynamic changes during anesthesia, BIS changes during anesthesia, and the incidence of intraoperative adverse events.

RESULTS: The incidence of PONV within 24 h postoperatively was significantly lower in the DD group than in the DN group (17.2% vs 31.9%), with a statistically significant difference. No significant differences were found between the two groups in the incidence of postoperative adverse events within 24 h, patient satisfaction, hemodynamic changes during anesthesia, BIS changes during anesthesia, or the incidence of intraoperative adverse events. No specific adverse effects of droperidol were observed in the DD group.

CONCLUSION: For patients undergoing gynecological day surgery under ciprofol-alfentanil general anesthesia, the combination of dexamethasone and droperidol is significantly more effective than dexamethasone alone in preventing PONV, with no significant difference in safety between the two regimens.

PMID:42472077 | PMC:PMC13380276 | DOI:10.2147/DDDT.S625824