Nevin Manimala

Ecotoxicol Environ Saf. 2025 Sep 2;303:118981. doi: 10.1016/j.ecoenv.2025.118981. Online ahead of print.

ABSTRACT

BACKGROUND: Carotid atherosclerosis (CAS) is a major contributor to cerebrovascular incidence and mortality, yet its etiology in non-dyslipidemic individuals remains poorly understood. Emerging evidence suggests that environmental metal exposure may play a critical role in CAS development.

METHODS: We conducted a retrospective matched case-control study involving 1290 non-dyslipidemic middle-aged and elderly individuals to examine the association between urinary metal exposure and CAS. Twenty-eight urinary metals were measured using inductively coupled plasma mass spectrometry (ICP-MS), and statistical analyses-including conditional logistic regression, weighted quantile sum (WQS) regression, and Bayesian kernel machine regression (BKMR)-were applied to assess single and mixed-metal effects. Mediation analysis was performed to evaluate the potential role of metabolic and inflammatory clinical indicator.

RESULTS: Conditional logistic regression found that six metals (OR_Q4vsQ1=1.63, 95 %CI: 1.14-2.34 for lithium (Li); OR_Q4vsQ1= 1.65, 95 %CI: 1.16-2.35 for titanium (Ti); OR_Q4vsQ1= 1.53, 95 %CI: 1.07-2.22 for cobalt (Co); OR_Q4vsQ1= 1.77, 95 %CI: 1.24-2.51 for nickel (Ni); OR_Q4vsQ1= 1.93, 95 %CI: 1.33-2.79 for copper (Cu), and OR_Q4vsQ1= 2.14, 95 %CI: 1.45-3.18 for cadmium (Cd)) were significantly associated with increased CAS risk, while selenium (Se) (OR _Q2vsQ1 = 0.65, 95 %CI: 0.46-0.93, OR_Q2vsQ1 = 0.59, 95 %CI: 0.41-0.84) was negatively associated with the risk of CAS. Mixed-metal exposure analyses, including WQS (OR=1.35, 95 %CI 1.12-1.63) and BKMR, consistently demonstrated a positive correlation with CAS, primarily driven by Ti. Mediation analysis further revealed that 11.54 % of association between Cu and CAS explained by remnant cholesterol (RC).

CONCLUSION: Our findings revealed a significant correlation between environmental metal exposure and CAS, independent of traditional lipid abnormalities. Future prospective studies are warranted to confirm these associations and elucidate the underlying biological mechanisms, potentially guiding targeted prevention strategies.

PMID:40902247 | DOI:10.1016/j.ecoenv.2025.118981

Drug Alcohol Depend. 2025 Aug 22;276:112848. doi: 10.1016/j.drugalcdep.2025.112848. Online ahead of print.

ABSTRACT

INTRODUCTION: Through secondary data analyses, we investigated sex differences in the effects of IQOS, a heated tobacco product, on combustible cigarette smoking.

METHODS: Adults who smoke cigarettes (N = 118; 21-65 years old) completed a baseline ad-lib smoking period (days 1-5), two laboratory visits (days 6-7), and a 14-day period where they were instructed to switch from smoking cigarettes to using IQOS 3.0 (days 8-21). Models estimated the changes in cigarettes smoked per day (CPD) and the percentage of baseline CPD substituted by HeatSticks during the switch period. Bivariate statistics assessed sex differences in covariates and IQOS-associated effects (i.e., subjective reward, relative reinforcing value, craving relief, and withdrawal relief) for model inclusion.

RESULTS: Males and females significantly reduced their CPD to 29.8 % and 21.8 % of their baseline CPD by the end of the switch period, respectively. CPD slopes were significant for males (β =-0.46/day [CI95 % -0.97 to -0.04] p = 0.002) and females (β =-0.83/day [CI95 % -1.34 to -0.31] p < 0.001), although slopes did not significantly differ (p = 0.3). Males and females substituted HeatSticks at 83.2 % and 67.4 % of their baseline CPD across the switch period. The IQOS slopes were significant for males (β =1.136/day [CI95 % 0.59-2.14] p = 0.001) but not females (β =0.64/day [CI95 % -0.67-1.94] p = 0.34), although the slopes did not significantly differ (p = 0.36). There were no significant sex differences in IQOS-associated effects (all p values > 0.05).

CONCLUSIONS: Males and females do not appear to differ in IQOS-associated effects or the initial substitutability of IQOS for combustible cigarettes.

PMID:40902222 | DOI:10.1016/j.drugalcdep.2025.112848

Clin Nutr. 2025 Aug 23;53:109-118. doi: 10.1016/j.clnu.2025.08.025. Online ahead of print.

ABSTRACT

BACKGROUND & AIMS: The association between meat intake and breast cancer risk remains unclear. This study examined the relationship between specific types of meat intake and breast cancer risk in a prospective cohort study.

METHODS: This study included 71,264 women aged 40-69 years from the Health Examinees-Gem (HEXA-G) study (2004-2013). Cancer diagnosis was identified via the Korea Central Cancer Registry and death certificate-linked data were provided by the Korea National Statistical Office until 31 December 2018. Cox proportional hazards models were used to estimated multivariate hazard ratios (HRs) and 95 % confidence intervals (CIs) for breast cancer risk by meat intake.

RESULTS: During 655,566.9 person-years of follow-up, 713 breast cancer cases were identified. Women who consumed one or more servings of processed meat per week had a 57 % increased risk of breast cancer (HR = 1.57, 95 % CI: 1.09-2.27, p for trend = 0.003), compared to those who did not consume processed meat. Stronger associations were observed among women under 50 years of age (p for trend = 0.021), with no family history of breast cancer (p for trend = 0.001), no regular exercise (p for trend = 0.028), no alcohol consumption (p for trend = 0.002) and a body mass index (BMI) below 25 kg/m² (p for trend = 0.005). Beef intake was associated with a potential reduction in breast cancer risk (HR = 0.82, 95 % CI: 0.67-1.01, p trend = 0.051, for 2 or more servings per month vs. none). Also, reduction of breast cancer risk was observed in women who consumed alcohol (p for trend = 0.036). More pronounced associations were found in women without family history of breast cancer (p for trend = 0.049), and in women who did not engage in regular exercise (p for trend = 0.015).

CONCLUSIONS: Our results suggest that processed meat intake is linked to a higher risk of breast cancer, whereas beef consumption may reduce the risk of breast cancer.

PMID:40902216 | DOI:10.1016/j.clnu.2025.08.025

Semin Arthritis Rheum. 2025 Aug 28;74:152822. doi: 10.1016/j.semarthrit.2025.152822. Online ahead of print.

ABSTRACT

OBJECTIVE: A revision of the 2017 EULAR-ACR myositis classification criteria, namely EULAR-ACR funded Myositis Revision of Classification (MyoROC) project, is currently underway involving a large international group of experts. In the first phase of this project, we identified additional items to be tested in the criteria.

METHODS: We distributed an electronic survey to International Myositis Assessment and Clinical Studies (IMACS) members to identify new items. The identified items were discussed within the Steering Committee and a multi-step Delphi consensus process consisting of an open discussion and three rounds of e-voting were conducted to reach the final item list.

RESULTS: The IMACS survey results revealed 24 new items. After an open discussion with Steering Committee members, 14 items were dropped and five new items were added, resulting in a total of 15 items. After three rounds of e-voting, the following variables were agreed to be tested in addition to the original items: finger flexion, knee extension ≥ hip flexion weakness, myonecrosis pattern on biopsy, magnetic resonance imaging and electromyography findings of myositis, additional rashes, skin biopsy, capillaroscopy, interstitial lung disease, arthritis, Raynaud’s phenomenon, myositis-specific (MSA) and -associated autoantibodies, enzyme elevation at ≥2 time points, and aldolase.

CONCLUSION: The new items that will be tested in the revised criteria were generated with input from a wide range of stakeholders and included, most importantly, MSA, pattern of weakness, skin changes, and additional diagnostic modalities. The next steps of the project are data collection followed by statistical analysis for development and validation of the revised criteria.

PMID:40902212 | DOI:10.1016/j.semarthrit.2025.152822

JMIR Med Educ. 2025 Sep 3;11:e65053. doi: 10.2196/65053.

ABSTRACT

BACKGROUND: The necessity for self-regulated, lifelong learners in the rapidly evolving field of medicine underscores the importance of effective study skills. Efforts to support students with these skills have had positive outcomes but are often limited in scope and accessibility, with a tendency to target groups facing immediate challenges.

OBJECTIVE: This study aimed to explore the student perspective on study skills support at University College London Medical School through a student-staff partnership, with the goal of guiding future improvements.

METHODS: A mixed methods approach was adopted using an anonymous questionnaire and focus groups. After analyzing questionnaire responses using descriptive statistics to refine focus group questions, focus groups were conducted to delve deeper into identified issues. Transcripts were analyzed thematically using inductive coding.

RESULTS: In total, 116 students completed the questionnaire in full and 6 students participated in 2 focus groups. The questionnaire revealed that 68% (68/100) of respondents felt that they never received study skills support at University College London Medical School. Preferred methods of support included small group sessions (56/100, 56%) and topics like examination preparation (83/100, 83%) and study skills specific to medicine (72/100, 72%). Focus group themes were the lack of current study skills support, delivery of study skills support, specific study skills for medical school, personalized approach to support needed, and accessing support. Findings informed the co-creation of study skills resources.

CONCLUSIONS: Overall, the findings highlight the need for strategically incorporating study skills support at medical school, emphasizing early and consistent promotion and tailored delivery methods.

PMID:40902194 | DOI:10.2196/65053

Medwave. 2025 Sep 3;25(8):e381. doi: 10.5867/medwave.2025.08.3081.

ABSTRACT

INTRODUCTION: The COVID-19 pandemic had a major impact on emergency services, including stroke care. Changes in the administration times of brain reperfusion therapies for stroke have been little explored in Chile. The aim of this study was to analyze the impact that the pandemic had on critical stroke treatment times, the number of patients treated, clinical severity, and the presence of major vessel occlusion.

METHODS: We performed a retrospective analysis of patients undergoing encephalic reperfusion therapy in a hospital in Valparaíso, Chile. Two groups of patients treated one year before (pre-pandemic group) and one year after (pandemic group) the start of health restrictions were compared.

RESULTS: 104 patients were included, with a mean age of 67.4 ± 13 years and a clinical severity of 13.5 ± 6.5 in the NIHSS. 91.5% received thrombolytic therapy. No significant intergroup differences were found in the metrics of treatment time, number of patients treated, clinical severity, or presence of major vessel occlusion. Although there was a non-significant trend towards delayed institutional therapeutic times, a significant correlation was found suggesting that the shorter the time from symptom onset to door, the shorter the time to access therapy (r = 0.84).

CONCLUSIONS: There were no significant differences in the therapeutic times of stroke in the period prior to the COVID-19 pandemic and the pandemic period, showing similarities to the experience reported in Chile and highlighting the adaptation of the health system during the health crisis. Studies with more complex epidemiological designs analyzing larger samples of patients will allow us to complement these results.

PMID:40902137 | DOI:10.5867/medwave.2025.08.3081

J Clin Oncol. 2025 Sep 3:JCO2402644. doi: 10.1200/JCO-24-02644. Online ahead of print.

ABSTRACT

PURPOSE: Patients with advanced, well-differentiated extrapancreatic neuroendocrine tumors (epNETs) have limited systemic treatment options. Pazopanib, an oral multikinase inhibitor with activity against vascular endothelial growth factor receptor (VEGFR)-2 and -3, PDGFR-alpha and-beta, and c-Kit, was tested for efficacy in epNET.

PATIENTS AND METHODS: We conducted a multicenter, randomized, double-blind, phase II study of pazopanib (800 mg once daily) versus placebo in low- to intermediate-grade epNET with radiologic progressive disease (PD) within 12 months of study entry. Previous somatostatin analog (SSA) was required for midgut tumors, and concurrent SSA was allowed. The primary end point was progression-free survival (PFS) by blinded independent central review. Unblinding and crossover were allowed if PD was confirmed by central review.

RESULTS: One hundred seventy-one patients (97 pazopanib and 74 placebo) were randomly assigned between September 2013 and October 2015. The majority had a midgut primary site (75%) and previous SSA treatment (93%). About half (49%) of the patients had functional tumors. The median follow-up was 61 months (95% CI, 60 to 63). Median PFS was 11.8 versus 7.6 months in pazopanib versus placebo, respectively (hazard ratio, 0.54 [95% CI, 0.37 to 0.79]; P < .001); 49 placebo patients crossed over to pazopanib. There was no significant difference in overall survival between the treatment arms. Rates of grade 3 or greater adverse events (regardless of attribution) were higher in pazopanib versus placebo (84% v 47%; P < .001), as were grade 5 death events (8% v 0%, P = .017).

CONCLUSION: Pazopanib compared with placebo significantly improves PFS in patients with progressive epNET, confirming that the VEGF signaling pathway is a valid target for therapy in epNET. However, after integrating the associated risks relative to the benefits, further development of pazopanib in this clinical context is not planned.

PMID:40902132 | DOI:10.1200/JCO-24-02644

Eur J Prev Cardiol. 2025 Sep 3:zwaf573. doi: 10.1093/eurjpc/zwaf573. Online ahead of print.

ABSTRACT

BACKGROUND AND AIMS: The most recent guidelines from the European Society of Cardiology (ESC) categorize blood pressure (BP) into three groups: (1) non-elevated BP, (2) elevated BP and (3) hypertension. This study aimed to determine whether the 2024 guidelines from the ESC for elevated BP and hypertension accurately identify populations at increased risk of future cardiovascular diseases.

METHODS: In a population-based cohort derived from the Korean National Health Insurance Service database, we included individuals aged ≥40 years who underwent national health examinations in 2009. Those with a history of stroke or myocardial infarction were excluded. Multivariable Cox proportional hazards models were used to assess the association between blood BP categories and the risk of the composite outcome (stroke, myocardial infarction, and all-cause mortality). Risk estimates based on the 2023 European Society of Hypertension (ESH) classification were also analyzed to illustrate differences in categorization.

RESULTS: A total of 2,604,340 participants were included in the final analysis, with a mean follow-up duration of 11.66 ± 2.25 years. Compared to the non-elevated BP group, both the elevated BP and hypertension groups showed significantly higher risks for the composite outcome (adjusted hazard ratio [aHR] 1.072 (95% CI: 1.059-1.084) and 1.201 (95% CI: 1.186-1.217)). The risks of stroke, myocardial infarction, and all-cause mortality were likewise significantly elevated in both the elevated BP and hypertension groups, respectively. Applying both the ESC and ESH frameworks demonstrated how differing BP thresholds can result in variation in risk assessment across population subgroups.

CONCLUSIONS: Elevated BP and hypertension, as defined by the 2024 ESC guidelines, were associated with increased risk of future cardiovascular events. While findings were directionally consistent with the 2023 ESH classification, the ESC framework identified a broader at-risk population. These results indicate that individuals with elevated BP, as defined by the 2024 ESC classification, have a modestly higher risk of cardiovascular events, particularly ischemic stroke, compared with those with non-elevated BP.

PMID:40902101 | DOI:10.1093/eurjpc/zwaf573

J Healthc Manag. 2025 Sep-Oct 01;70(5):369-383. doi: 10.1097/JHM-D-24-00153. Epub 2025 Sep 2.

ABSTRACT

GOAL: In 2024, the Centers for Medicare & Medicaid Services (CMS) introduced equity metrics for healthcare systems to document social determinants of health (SDOH). Payment determinations were also linked to readmission performance measures. Readmission prevention programs for vulnerable patients, defined by CMS as dually eligible (DE) for Medicare and Medicaid, racial/ethnic minorities, and those with disabling conditions, have the potential to reduce readmission disparities. Our goal was to develop a systematic and pragmatic approach to collect, analyze, and utilize SDOH and insurance status to assign patients to an intensified protocol for reducing readmission disparities after coronary artery bypass grafting (CABG).

METHODS: Patients admitted to a major urban medical center for isolated CABG from October 2023 to October 2024 (N = 286) completed a standardized clinician-assisted SDOH questionnaire. SDOH risk was adapted from ICD-10 Z codes that targeted social risk factors within the scope of healthcare providers’ practices (i.e., language barriers, health literacy, access to a heart-healthy diet, lack of transportation to postoperative appointments, financial difficulties impeding access to prescription medications or medical care, and lack of a caregiver/social support). Project managers reviewed electronic health records and documented racial/ethnic categories using current CMS recommendations. SDOH+ (positive) and Medicaid or DE patients were assigned to a vulnerable patient intensified protocol (VPIP) readmission prevention program focused on education, deployment of hospital and community-based resources, transportation assistance, and increased frequency of postoperative follow-up. Non-VPIP patients continued their surgeons’ usual care protocols.

PRINCIPAL FINDINGS: Of the 286 isolated CABG patients, 55% were ≥65 years old, 80% were male, 47% were White, 24% had Medicaid, and 14% were DE. The most prevalent SDOH+ responses were the need for an interpreter (31%), low health literacy or less than a high-school education (23%), and transportation issues (17%). White patients were significantly (p < .05) less likely to qualify for VPIP than non-White patients, as were patients with Medicare compared to those with self-pay, commercial, or military insurance. Overall, 27% of patients had ≥2 SDOH risk factors. The need for an interpreter was 6.6 times more likely to be associated with having Medicaid or being DE than not. Low health literacy or less than a high school education, transportation issues, and the lack of access to a heart-healthy diet were all significantly associated with Medicaid or DE patients. White patients, compared to non-White patients or unknown or declined responses, were significantly less likely to be SDOH+ (13% vs. 39%, p < .0001). Asian patients were at a higher risk for SDOH+ compared to White patients (49% vs.13%, p < .0001), and among Asian patients, 29% had neither Medicaid nor DE status. The strongest predictor of SDOH+ status in logistic regression models was Medicaid or DE status compared to all other insurance types (OR = 5.4, confidence interval [3.0-9.9]) when adjusted for age, race/ethnicity, and gender.

PRACTICAL APPLICATIONS: Our findings demonstrate that a social-risk-informed care model is feasible in a hospital-based CABG readmission prevention program. Vulnerable patients can be identified through the standardized collection of SDOH, insurance status, and race/ethnicity data. Insurance status may be an excellent proxy to ascertain social risk and is readily accessible. Other healthcare organizations should consider regional demographics for possible SDOH risk. Our findings may support other initiatives to improve the collection of SDOH and demographic information. The VPIP CABG readmission prevention program could be adapted for other conditions and settings to achieve equitable care.

PMID:40902098 | DOI:10.1097/JHM-D-24-00153

JMIR Med Inform. 2025 Sep 3;13:e68613. doi: 10.2196/68613.

ABSTRACT

BACKGROUND: The primary health care service in Indonesia consists of 10,260 public health centers (Puskesmas), which play a major role in providing health care in the community, recording and reporting health data using digital health information systems (HIS) or manual reports. The utilization of HIS across Puskesmas is crucial to capture the dynamic evolution of health problems and monitor interventions, thus providing effective primary health care services for the community.

OBJECTIVE: This paper provides a national-level baseline mapping of HIS utilization in Indonesian Puskesmas. It evaluates the number of HIS used, associated challenges, and contextual factors influencing system adoption.

METHODS: A cross-sectional survey was carried out covering all Puskesmas across 34 Indonesian provinces between January and February 2022. The questionnaire covered a list of HIS used by Puskesmas, which developed the HIS, and the utilization and challenges during HIS implementation. Descriptive statistical analysis and bivariate analysis were applied.

RESULTS: A total of 2606 (25.5%) public health centers across 34 provinces participated in this study. On average, Puskesmas reported using 30 different HIS platforms, with notable variation across provinces and islands. Most systems (n=62,060, 72.94%) were developed by national ministries, though local governments and third parties also contributed. Despite 91.5% of respondents reporting that HIS aligned with their needs and 90% claiming data use for decision-making, many centers faced operational barriers: 49% (n=132,300) of systems required excessive data entry, 33% (n=89,100) experienced frequent downtime, and 29% (n=78,300) lacked automated analysis features. In terms of the infrastructure supporting HIS implementation, 9.45% (n=138) of Puskesmas have no access to the internet, while only 28.9% (n=422) have access to robust and efficient internet connections. As for the human resources, the study reveals that each health personnel manages up to six different HIS for data reporting tasks, 74.30% (n=1133) of Puskesmas only received training at the initial system’s implementation stage, and 80.51% (n=1225) of respondents report the existence of an informal knowledge transfer process among the staff. The bivariate analysis shows that Puskesmas with the characteristics of being located in Java island and urban areas possessed higher accreditation levels, had more training and knowledge transfer, and had a greater chance to use >30 HIS.

CONCLUSIONS: This descriptive study highlights substantial fragmentation in Indonesia’s HIS environment and reveals critical disparities in system infrastructure, usability, and workforce capacity. Recommendations should be tailored to different contexts: offline-compatible systems and basic digital literacy training are needed in rural areas, while urban Puskesmas may benefit from advanced integration and analytics tools. Future research should address HIS interoperability, impact assessment, cost-effectiveness, and qualitative user experience through longitudinal and mixed methods studies to guide Indonesia’s digital health transformation.

PMID:40902076 | DOI:10.2196/68613