Nevin Manimala

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

Ital J Pediatr. 2026 Jul 18. doi: 10.1186/s13052-026-02312-8. Online ahead of print.

ABSTRACT

BACKGROUND: Pediatric female dystrophinopathy may be asymptomatic at evaluation or may show skeletal muscle and cardiac manifestations, but childhood presentations are often subtle. We aimed to characterize the clinical spectrum, ascertainment pathways, subclinical muscle involvement, and inheritance patterns in this population.

METHODS: This single-center retrospective case series was conducted between January 2024 and December 2025 and included 35 girls with genetically confirmed DMD gene variants identified from existing clinical records. Primary ascertainment route was recorded separately from cross-sectional clinical status at evaluation and classified as symptom-driven presentation, incidental or unexplained hyperCKemia, family-based cascade screening, or incidental genomic discovery. Clinical status at evaluation was assigned after systematic clinical review with reference to published female dystrophinopathy classifications. Statistical analyses were exploratory.

RESULTS: The median age was 5 years (range, 1-10). Primary ascertainment routes were symptom-driven presentation in 8/35 (22.9%), incidental or unexplained hyperCKemia in 18/35 (51.4%), family-based cascade screening in 8/35 (22.9%), and incidental genomic discovery in 1/35 (2.9%). After systematic clinical review, clinical status at evaluation was classified as asymptomatic in 29 participants, BMD-like in 1, DMD-like in 3, and cardiac-symptom/CMR observations in 2. All 18 girls initially identified through incidental or unexplained hyperCKemia were classified as asymptomatic because no muscle weakness was documented on neurological examination, although some had exercise intolerance, easy fatigue, myalgia, or cramps. EMG abnormalities were identified in 14/34 participants, including definite myopathic findings in 5 and subtle short-duration motor-unit-potential changes in 9. Variants were apparently de novo in 15 cases, maternally inherited in 18, and paternally inherited in 2, including one case inherited from a father with low-level mosaicism in peripheral blood.

CONCLUSIONS: Pediatric female dystrophinopathy shows a broad childhood spectrum and may be recognized before objective muscle weakness is documented. Separating ascertainment route from clinical status highlights recurrent or persistent hyperCKemia and mild exercise-related complaints as practical entry points for targeted neuromuscular assessment and longitudinal follow-up. Earlier recognition in childhood may support timely neuromuscular and cardiac surveillance, parental evaluation when appropriate, family-based genetic counseling, and future reproductive planning.

PMID:42471751 | DOI:10.1186/s13052-026-02312-8

J Cardiothorac Surg. 2026 Jul 18. doi: 10.1186/s13019-026-04541-8. Online ahead of print.

ABSTRACT

BACKGROUND: Pulmonary complications after coronary artery bypass surgery continue to be a significant problem, affecting 5-20% of patients, prolonging hospital stays and increasing costs. In this study, we investigated whether simple blood tests that measure inflammation, such as the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and systemic immune-inflammation index (SII), could help identify patients at risk before surgery.

METHODS: The records of 1034 patients who underwent elective coronary artery bypass grafting with heart-lung machine support between 2023 and 2024 were retrospectively reviewed. NLR, PLR, and SII values were calculated from routine blood tests performed the day before surgery. Patients who developed pulmonary complications were defined according to the European Perioperative Clinical Outcome (EPCO) definitions.

RESULTS: 114 patients (11%) developed PPC. Preoperative inflammatory markers were significantly higher in patients with complications (NLR: 3.55 ± 1.07 vs. 1.79 ± 0.54, PLR: 156 ± 47 vs. 120 ± 36, SII: 825 ± 248 vs. 548 ± 164; all p < 0.001). ROC analysis demonstrated excellent discrimination for NLR (AUC 0.939), good for SII (AUC 0.818), and fair-to-good for PLR (AUC 0.724). In multivariate analysis, NLR was by far the strongest independent predictor of PPC, together with COPD, diabetes, active smoking, CPB and ACC durations. PLR and SII also reached statistical significance, but with effect sizes very close to unity (adjusted OR 1.02 and 1.01 respectively), indicating that they offered minimal additional discriminatory value once NLR was taken into account.

CONCLUSIONS: In this single-center retrospective cohort, preoperative NLR, PLR and SII were associated with PPC, with NLR accounting for most of the predictive signal. Because they are measured at a single preoperative timepoint, these indices reflect baseline inflammatory tone and cannot capture the acute, surgery-induced inflammatory response that drives postoperative pulmonary complications. In view of the single-center retrospective design, the absence of external validation, and the lack of comparison with validated risk scores such as EuroSCORE II or the STS score, these indices are not yet suitable to guide clinical decision-making on their own. Given their simplicity and ready availability, however, they appear to be promising candidate markers that merit further evaluation in prospective, multicenter studies also incorporating specific inflammatory mediators measured dynamically throughout the perioperative period.

PMID:42471737 | DOI:10.1186/s13019-026-04541-8