Nevin Manimala

JMIR Public Health Surveill. 2025 Nov 21;11:e62693. doi: 10.2196/62693.

ABSTRACT

BACKGROUND: Despite the wide variety of studies that have focused on the recent COVID-19 infodemic, defining health mis- or disinformation remains a challenge due to the dynamic nature of the social media ecosystem and, in particular, the different terminologies from different fields of knowledge.

OBJECTIVE: In this work, we aim to develop a conceptual framework of health misinformation during pandemic contexts that will enable the establishment of an interoperable definition of this concept and consequently a better management of these problems in the future.

METHODS: We conducted a systematic review of reviews to develop a conceptual framework for health misinformation during the pandemic context as a case study.

RESULTS: This review comprises 51 reviews from which we developed a conceptual framework that integrates 6 key domains-sources, drivers, content, dissemination channels, target audiences, and health-related effects of mis- or disinformation-offering a structured approach to analyze and categorize health misinformation. These 6 domains collectively form the basis of our proposed conceptual framework.

CONCLUSIONS: Our results highlight the complexity and multifaceted nature of health disinformation and underscore the need for a common language across disciplines addressing this global problem in order to use interoperable definitions and advance this evolving field of study. By offering a structured conceptual framework, we also provide a valuable foundation for interventions aimed at surveillance, public communication, and digital content moderation in future health emergencies.

PMID:41269748 | DOI:10.2196/62693

JAMA Health Forum. 2025 Nov 7;6(11):e254241. doi: 10.1001/jamahealthforum.2025.4241.

ABSTRACT

IMPORTANCE: With hospital-based obstetric care declining in rural areas, risk-appropriate care, which aligns patient clinical conditions with hospital capabilities using level of care, may be limited for pregnant rural residents, especially those with higher-risk conditions that necessitate specialty or subspecialty obstetric care.

OBJECTIVE: To assess the proportion of higher-risk pregnant rural residents who receive risk-appropriate care during childbirth and identify factors associated with not receiving risk-appropriate care.

DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study used linked vital statistics and hospital discharge data for pregnant rural residents with higher-risk clinical conditions who had hospital-based births in Michigan (2010-2020), Oregon (2010-2020), Pennsylvania (2010-2018), and South Carolina (2010-2020). Data analyses were performed between December 2023 and July 2025.

EXPOSURE: Birth hospital maternal level of care (I, basic; II, specialty; III, subspeciality; IV, regional perinatal).

MAIN OUTCOMES AND MEASURES: The main outcome was birth in a hospital with risk-appropriate care, defined as having the necessary level of care for the patient’s clinical condition. Covariates included age, race and ethnicity, insurance, education, prenatal care utilization, medical and obstetric comorbidities, distance to the closest risk-appropriate hospital (quartile 1: 0.50-5.57 miles, quartile 2: 5.58-18.90 miles, quartile 3: 18.91-33.93 miles, quartile 4: 33.94-209.80 miles), year, and state.

RESULTS: A total of 199 225 higher-risk pregnant rural residents (mean [SD] maternal age, 27.9 [5.6] years) were included, of whom 11 651 (5.9%) identified as Hispanic, 3054 (1.5%) as non-Hispanic American Indian or Alaska Native, 1370 (0.7%) as non-Hispanic Asian or Pacific Islander, 18 296 (9.2%) as non-Hispanic Black, 5320 (2.7%) as non-Hispanic other race, and 159 253 (79.9%) as non-Hispanic White. Birth at a risk-appropriate hospital occurred for 38 441 of 70 647 individuals (54.4%) with conditions requiring level II care, 4611 of 9270 (49.7%) with conditions requiring level III care, and 1793 of 6527 (27.5%) with conditions requiring level IV care. Those with significantly higher rates of not receiving risk-appropriate care included American Indian or Alaska Native (adjusted incidence rate ratio [aIRR], 1.13; 95% CI, 1.10-1.17), or Hispanic (aIRR, 1.06; 95% CI, 1.03-1.08) individuals (compared with White individuals), those without private insurance (public: aIRR, 1.03; 95% CI, 1.01-1.04; uninsured: aIRR, 1.07; 95% CI, 1.01-1.14), those who were younger and had less education (age <20 years: aIRR, 1.05; 95% CI, 1.03-1.08, compared with 30-34 years; some high school: aIRR, 1.04; 95% CI, 1.03-1.06, compared with high school degree), and those who lived further from a risk-appropriate hospital (furthest quartile: aIRR, 23.86; 95% CI, 20.48-27.79, compared with closest quartile).

CONCLUSIONS AND RELEVANCE: In this study, lack of risk-appropriate care was common for pregnant rural residents with clinical complexity. Associated factors, including race, ethnicity, insurance, age, education, and distance, highlight the barriers and need for increasing access to subspecialty care for pregnant rural residents.

PMID:41269701 | DOI:10.1001/jamahealthforum.2025.4241

JAMA Health Forum. 2025 Nov 7;6(11):e254403. doi: 10.1001/jamahealthforum.2025.4403.

ABSTRACT

IMPORTANCE: Dentists’ limited participation in Medicaid is a substantial barrier to addressing the persistent unmet need for dental care among adult Medicaid beneficiaries.

OBJECTIVE: To assess dentists’ experiences and perceptions regarding Medicaid and to identify barriers and facilitators to participation as well as strategies to improve dentists’ participation and service delivery.

DESIGN, SETTING, AND PARTICIPANTS: This qualitative study involved semistructured individual interviews of dentists from 8 states (Maryland, Massachusetts, Michigan, New York, North Carolina, South Dakota, Wisconsin, Wyoming) about their experiences with and perceptions of Medicaid. The study was conducted between August 2022 and July 2023. Data were analyzed from September 2023 to September 2024.

MAIN OUTCOMES AND MEASURES: Themes related to Medicaid participation were identified through thematic analysis, and descriptive statistics were used to characterize the sample.

RESULTS: Of the 67 dentists interviewed, 46 (68.6%) accepted Medicaid, and 21 (31.3%) did not accept Medicaid. The sample consisted of 36 females (53.7%) and 31 males (46.3%), with a mean (SD) age of 45.1 (14.4) years and a mean (SD) of 16.4 (13.8) years of work experience. Three key domains affecting dentists’ participation in Medicaid were identified: system-level, dentist-level, and patient-level factors. At the system-level domain, barriers to Medicaid acceptance, including low reimbursement rates, administrative burdens, restrictive benefit designs, and poor communication about benefits, played a role in perceived inefficiencies and limited dentists’ engagement. Challenges at the dentist-level domain included language barriers, capacity constraints, stigma surrounding Medicaid, and concerns about financial sustainability. Factors at the patient level, including appointment adherence, unfavorable perceptions of preventive care, logistical barriers, and limited oral health literacy, had a potential role in limiting effective care delivery. Dentists who accepted Medicaid reported frustration with administrative inefficiencies and reimbursement rates, whereas those who did not participate in Medicaid emphasized financial stability concerns.

CONCLUSIONS AND RELEVANCE: This study highlights the complex interplay of barriers and facilitators at system, dentist, and patient levels that impact oral health care delivery to adult Medicaid beneficiaries. Increasing reimbursement rates is important but should be complemented by efforts to streamline administrative processes, improve patient engagement, and support dentists through targeted incentive programs.

PMID:41269700 | DOI:10.1001/jamahealthforum.2025.4403

JAMA Netw Open. 2025 Nov 3;8(11):e2541409. doi: 10.1001/jamanetworkopen.2025.41409.

ABSTRACT

IMPORTANCE: Infants in neonatal intensive care units (NICUs) are at risk of acquiring organisms with multidrug resistance or high epidemic potential (MDRO+), which may precede invasive infections. High-resolution analysis of transmission cultures of MDRO+ may help mitigate these risks through targeted infection prevention measures.

OBJECTIVES: To assess the potential of whole-genome sequencing in resolving suspected transmission chains of MDRO+ and to identify associated risk factors for cluster involvement.

DESIGN, SETTING, AND PARTICIPANTS: This prospective monocentric cohort study was conducted at a level III NICU at the Medical Center-University of Freiburg, Freiburg, Germany. Of 551 admitted infants, 434 were included because they remained on the ward for 48 hours or more and received 1 or more screenings between February 15, 2019, and November 16, 2020. Statistical analysis was conducted from December 1, 2021, to November 10, 2024.

EXPOSURES: Time-dependent patient- and ward-level factors, medical device use, nursing effort score, invasive procedures, antibiotic use, prevalence of MDRO+, and staffing metrics were analyzed for association with transmission chains.

MAIN OUTCOMES AND MEASURES: The primary outcome was transmission of MDRO+, defined as colonization or invasion with genetically indistinguishable bacteria, defined by amplified fragment length polymorphism or whole-genome sequencing. Secondary outcomes included colonization rates, bloodstream infections, and risk factors associated with transmission.

RESULTS: The study included 434 infants (median gestational age, 34.6 weeks [IQR, 31.4-38.3 weeks]; 242 boys [55.8%]; median birth weight, 2165 g [IQR, 1410-2965 g]). Overall, 225 patients (51.8% [95% CI, 47.1%-56.5%]) were colonized with at least 1 MDRO+. Of 418 unique colonizations, 142 (34.0% [95% CI, 29.6%-38.6%]) were linked with transmission by whole-genome sequencing. Thirty-seven unique transmission clusters were identified, most frequently involving Escherichia coli (n = 11). Four of 10 bloodstream infections with MDRO+ (40.0%) were linked with transmission events. Increased full-time nurse staffing (odds ratio [OR], 0.28 [95% CI, 0.21-0.38]; P < .001) and prior antibiotic use (OR, 0.41 [95% CI, 0.26-0.63]; P < .001) were associated with decreased transmission risk, while vascular catheter use was associated with increased transmission risk (OR, 1.65 [95% CI, 1.26-2.17]; P < .001).

CONCLUSIONS AND RELEVANCE: This cohort study involving infants in the NICU suggests that bacterial sequencing can accurately detect bacterial transmission events. Multivariate analysis suggests that the bacterial transmission risk on a NICU can be modified.

PMID:41269695 | DOI:10.1001/jamanetworkopen.2025.41409

JAMA Netw Open. 2025 Nov 3;8(11):e2544535. doi: 10.1001/jamanetworkopen.2025.44535.

ABSTRACT

IMPORTANCE: Mobility limitations are common in older adults and impact quality of life and social interaction. Walking aids can improve mobility and prevent falls but require oversight and training. Despite being recommended by geriatric emergency department (ED) guidelines, their effectiveness in this setting has not been studied to date.

OBJECTIVE: To evaluate the effectiveness of training and provision of walking aids, with or without telemonitoring, on mobility, fear of falling, gait, functional capacity, quality of life, cognition, depression, and occurrence of falls in older adults after an ED visit compared with safe ambulation recommendations only.

DESIGN, SETTING, AND PARTICIPANTS: This randomized clinical trial was conducted at the Geriatric ED of Hospital Sírio-Libanês, São Paulo, Brazil, from July 20 to December 16, 2023, with a 90-day follow-up. Participants were patients 65 years or older who were discharged from the geriatric ED with at least 1 indication for walking aids according to the institutional protocol. Researchers involved in postintervention assessment and statistical analyses were blinded to group allocation.

INTERVENTION: Seventy-five participants were allocated to 1 of 3 groups: control, walking aids (WA), or walking aids with telemonitoring (WAT). All participants received safe ambulation recommendations. Intervention groups (WA and WAT) were assessed and trained in device use by a physiotherapist. The WAT group received telemonitoring follow-up to promote adherence.

MAIN OUTCOMES AND MEASURES: The primary outcomes were improved life-space mobility as assessed by the Life Space Assessment and fear of falling as assessed by the Falls Efficacy Scale International at 90 days follow-up. Secondary outcomes included gait, functional capacity, quality of life, cognition, depression, and occurrence of falls.

RESULTS: A total of 75 older adults were enrolled (mean [SD] age, 81.3 [7.7] years; 40 [53.3%] female). At 90 days, the WA group had significant improvement in life-space mobility (mean difference [MD], 12.77; 95% CI, 1.06-24.54; P = .03), fear of falling (MD, -5.60; 95% CI, -9.06 to -2.14; P = .002), and 1-minute sit-to-stand test (MD, 8.45; 95% CI, 4.34-12.56; P = .001) compared with the control group. No significant improvements were observed in any of these outcomes in the WAT group compared with the WA group.

CONCLUSIONS AND RELEVANCE: In this randomized clinical trial, training and provision of walking aids for older adults in the ED improved mobility and fear of falling as long as 90 days after discharge. The addition of telemonitoring did not result in additional benefits. This study highlights the role of a specialized physiotherapy intervention to optimize outcomes in older adults in the ED.

TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT05950269.

PMID:41269694 | DOI:10.1001/jamanetworkopen.2025.44535

JAMA Netw Open. 2025 Nov 3;8(11):e2545046. doi: 10.1001/jamanetworkopen.2025.45046.

ABSTRACT

IMPORTANCE: The incidence and prevalence of clinical Alzheimer disease (AD) are higher among Black and Latinx older adults than among White older adults. Past studies that compared plasma AD biomarker concentrations among groups minoritized by their race and ethnicity yielded inconsistent findings; however, these efforts did not include population representative samples or statistical procedures to ensure population representation.

OBJECTIVE: To examine race and ethnicity differences in plasma AD biomarker concentrations and in the association between biomarkers and medical conditions in a US population-representative cohort of middle-aged adults (approximately 58 years of age).

DESIGN, SETTING, AND PARTICIPANTS: Data for this cohort study came from the High School and Beyond sample, a nationally representative cohort of high school sophomores and seniors who were recruited in 1980. In 2021, a subset of participants provided blood samples that were assayed for amyloid-β (Aβ42/Aβ40 ratio), phosphorylated tau-181 (pTau-181), neurofilament light chain (NfL), and glial fibrillary acidic protein (GFAP). The analyses for the present study were conducted between July 2, 2024, and August 26, 2025, using data collected during the 2021 follow-up study.

EXPOSURES: Race and ethnicity groups and common medical conditions.

MAIN OUTCOMES AND MEASURES: General linear models with Wald tests were used to compare biomarker concentrations between race and ethnicity groups and to test interactions with common medical conditions using unadjusted biomarker values and models adjusted to ensure population representation with inverse probability weighting and multiple imputation.

RESULTS: The sample included 4340 adults (mean [SD; range] age, 58.1 [1.1; 56-63] years; 2400 [55.3%] women); 630 (14.4%) were Black, 900 (20.7%) were Latinx, and 2610 (60.1%) were White. Black participants had a lower Aβ42/Aβ40 ratio (d = -0.002; 95% CI, -0.004 to -0.000; P = .04) and lower NfL concentrations (d = -1.16; 95% CI, -2.15 to -0.16; P = .02) than White participants, but these differences were attenuated when models were adjusted for population representation (d = 0.000; 95% CI, -0.002 to 0.002; P = .85 for Aβ ratio; d = -0.88; 95% CI, -1.78 to 0.02; P = .05 for NfL). Latinx participants had lower GFAP concentrations than White participants (d = -3.87; 95% CI, -7.30 to -0.45; P = .03), but these differences were also attenuated when models were adjusted for population representation (d = 3.36; 95% CI, -3.13 to 9.86; P = .31). In general, estimated biomarker means were similar between race and ethnicity groups. History of type 2 diabetes was associated with increased NfL concentration (d = 0.19; 95% CI, 0.07 to 0.30; P = .04), and high body mass index was associated with lower Aβ42/Aβ40 ratio (d = -0.13; 95% CI, -0.21 to -0.06; P = .02); whereas high cholesterol was associated with lower pTau-181 concentration (d = -0.18; 95% CI, -0.25 to -0.10; P = .01) and high BMI was associated with lower GFAP concentration (d = -0.30; 95% CI -0.44 to -0.16; P = .01). No differences in associations between morbidities and AD biomarker concentrations were detected across race and ethnicity groups.

CONCLUSIONS AND RELEVANCE: In this cohort of middle-aged adults, the use of appropriate statistical estimation to ensure population representation indicated that blood-based AD biomarker concentrations were not distinguishable among race and ethnicity groups. Common medical conditions were associated with plasma biomarker concentrations similarly across race and ethnicity groups. These results highlight the importance of considering population representation and comorbid conditions in AD research to ensure accurate characterization of disease pathophysiology and improve precision of diagnostic and treatment strategies for populations that experience AD disparities.

PMID:41269690 | DOI:10.1001/jamanetworkopen.2025.45046

Environ Sci Pollut Res Int. 2025 Nov 21. doi: 10.1007/s11356-025-37103-x. Online ahead of print.

ABSTRACT

Microplastics (MPs) are ubiquitous in aquatic environments and closely tied to human activities, yet linking measured concentrations to urban pressures remains challenging. Methodological inconsistencies inflate variance, obscure spatial patterns, and hinder comparability. We therefore implemented fully harmonized sampling and FTIR-verified analysis across ten lakes in Latvia, Lithuania, and Poland, with all field and laboratory work performed by the same team. In parallel, we calculated an urbanization index to relate MP concentrations to shoreline development and urban influences. This design enabled comparisons of MPs in surface waters and sediments with ranges of 0.67-7.68 particles L⁻¹ (water) and 0.09-3.90 particles g⁻¹ dw (sediments). Polyethylene and polypropylene predominated, with fibres and fragments as the most common shapes; particles < 5 mm, and black, blue, or white, were most frequent. Shoreline urbanization, quantified by the shoreline urbanization index, was the only significant predictor of MPs in surface waters, explaining ~ 74% of variance, while nutrient concentrations, lake type, proximity to point sources, and season showed no consistent effect. Seasonal shifts in particle shape and type were observed but not in total abundance. MP concentrations were broadly similar among countries, with modest, statistically inconclusive differences in particle size and colour, indicating limited regional variation once methodological noise is removed. Our findings highlight that harmonized protocols sharpen the detection of environmental drivers and may overturn previously reported geographic differences driven by inconsistent methods. This first fully standardized, multi-lake, cross-country MP survey provides a robust framework for future monitoring and mitigation in inland waters.

PMID:41269591 | DOI:10.1007/s11356-025-37103-x

Dermatol Ther (Heidelb). 2025 Nov 21. doi: 10.1007/s13555-025-01603-y. Online ahead of print.

ABSTRACT

INTRODUCTION: Calcipotriol and betamethasone dipropionate (Cal/BDP) PolyAphron dispersion (PAD) cream and Cal/BDP foam have demonstrated superior efficacy to Cal/BDP gel in patients with plaque psoriasis exhibiting a more severe profile defined by the Rule of Tens in different studies. However, its comparative efficacy in this subgroup of patients needs to be studied.

METHODS: An indirect treatment comparison (ITC) using individual patient data for Cal/BDP PAD cream and available aggregated data for Cal/BDP foam was conducted for three outcome measures: Physician’s Global Assessment (PGA) success, modified Psoriasis Area and Severity Index 75 (mPASI75), and Dermatology Life Quality Index (DLQI) satisfaction. Bucher’s method was used for the ITC base case, and alternative analyses were performed using an anchored matching-adjusted indirect comparison (MAIC). Odds and risk ratios were calculated for each outcome.

RESULTS: After adjustment to the Rule of Tens, Cal/BDP PAD cream showed no differences vs. Cal/BDP foam in the three outcomes. Similar results were found for the MAIC scenarios after population matching, supporting the validity of the results.

CONCLUSION: In this ITC analysis, no significant differences in the clinical efficacy of Cal/BDP PAD cream and Cal/BDP foam in patients with plaque psoriasis meeting the Rule of Tens were observed considering their recommended treatment durations.

PMID:41269583 | DOI:10.1007/s13555-025-01603-y

BioDrugs. 2025 Nov 21. doi: 10.1007/s40259-025-00747-9. Online ahead of print.

ABSTRACT

Even though the use of biosimilar medicines is increasing across European countries, detailed and regularly published official data on biosimilar uptake are not publicly available except in Italy and Portugal. The main objective of this study was to provide a nationwide assessment of biosimilar consumption and uptake patterns in Spain between 2016 and 2023. Data were provided by the Ministry of Health and included the defined daily dose (DDD) of biosimilars (N = 17) dispensed through both community pharmacies and public hospitals, biosimilar market share, and information on the registration status of both the bio-originator and biosimilars of each active principle. Data were analysed using non-parametric tests and bootstrap analysis with 10,000 replications, considering market share, time since market entry, number of competitors, and indication type (acute vs. chronic). The results show that biosimilar penetration increased from 9% in 2016 to 47% in 2023. In 2023, the biosimilar market share was substantially higher in the hospital setting (68%) compared to community pharmacies (34%). Biosimilars indicated for acute conditions achieved significantly higher market shares than those used for chronic conditions (p < 0.05). A positive correlation was observed between market share and the number of competitors, which was statistically significant only in the hospital setting (p = 0.007), while no significant association was found in the community pharmacy setting. Additionally, no correlation was identified between biosimilar market penetration and the time elapsed since the introduction of the first biosimilar. Other factors, such as prices, tendering, interchangeability, patients’ characteristics, etc., may also influence biosimilar use. We suggest further analysis of policies aimed at promoting biosimilar adoption in Spain.

PMID:41269540 | DOI:10.1007/s40259-025-00747-9

Ultrasound J. 2025 Nov 21;17(1):61. doi: 10.1186/s13089-025-00469-7.

ABSTRACT

BACKGROUND: Focused cardiac ultrasound (FCU) is increasingly used as an extension of physical examination to aid diagnosis and clinical decision-making. Emerging educational technologies such as artificial intelligence (AI)-enabled ultrasound devices and virtual reality (VR) simulators offer novel, cost-effective and self-directed approaches for FCU skill acquisition training. Prior studies suggest that VR-based training may be non-inferior to traditional teaching, while AI offers real-time feedback to enhance learning.

OBJECTIVE: This study aimed to evaluate the effectiveness and non-inferiority of AI and VR-assisted training compared to Traditional in-person instruction in achieving competency in FCU image acquisition. Secondary outcomes included time to acquire an optimal apical 4 chamber (A4C) view and self-reported confidence in image acquisition, assessed immediately post-training and at 3-month follow up.

METHODS: In this single-blind, randomized controlled pilot trial, 66 local medical students with no prior FCU experience were randomised into 3 arms: (1) AI-enabled ultrasound training using the Kosmos system, (2) VR-based stimulator (Vimedix), and (3) Traditional instructor-led teaching. All sessions were 60 min long. Image acquisition of 5 standard FCU views was assessed by blinded evaluators using the Rapid Assessment of Competency in Echocardiography (RACE) score at both time points.

RESULTS: Two participants were lost to follow-up (one each from the AI and VR groups). In the first assessment, the Traditional group achieved the highest mean RACE score (15.77), followed by AI (13.39) and VR (13.23). Non-inferiority testing confirmed that both AI (95% CI -∞ to 3.60; p < 0.001) and VR (95% CI -∞ to 3.58; p < 0.001) methods were non-inferior to Traditional instruction. The AI group achieved the shortest mean time to acquire an optimal A4C view (158 ± 99.1 s), followed by the VR (189 ± 94.7 s), and traditional (199 ± 115.1 s), though differences were not statistically significant (p = 0.591). Confidence levels were initially highest in the Traditional group, while the VR group showed higher confidence at 3-month follow-up, particularly in parasternal long-axis view acquisition.

CONCLUSIONS: AI and VR-based training methods were non-inferior to traditional instruction for FCU skill acquisition. Both modalities show promise as scalable, technology-enabled alternatives in ultrasound education. Trial registration This trial was registered on Clinicaltrials.gov (NCT06355557).

PMID:41269495 | DOI:10.1186/s13089-025-00469-7