Nevin Manimala

Chin J Traumatol. 2026 Jul 31:S1008-1275(26)00146-X. doi: 10.1016/j.cjtee.2026.06.001. Online ahead of print.

ABSTRACT

PURPOSE: Non-union fractures of the lower extremity remain a major clinical challenge due to high mechanical loading, compromised vascularity, and limited soft-tissue coverage. Platelet-rich plasma (PRP) has emerged as a biological adjunct to enhance bone healing; however, its efficacy in non-union fractures is still debated. This review aimed to synthesize available evidence on reported outcomes of adjunctive PRP use in non-union lower extremity fractures.

METHODS: A comprehensive literature search up to 31st October 2025 was performed in PubMed, ScienceDirect, ProQuest, Cochrane, and Google Scholar in accordance with the Preferred Reporting Items for Systematic Reviews guidelines. Eligible studies included adult patients with non-union tibial or femoral fractures treated with PRP as platelet gel, platelet concentrate, or composite graft, compared with standard treatment or without PRP. The primary outcome was time to radiographic union, while radiographic non-union and complications were evaluated as secondary outcomes. Random-effects models with the DerSimonian-Laird method were used to calculate pooled effect sizes, and heterogeneity was assessed using I² statistics.

RESULTS: Seven studies involving 230 patients were included. Heterogeneous PRP-augmented surgical strategies significantly reduced time to radiographic union by 2.59 weeks compared with control (95% confidence intervals: -4.14 to -1.05; p < 0.001, I² = 0%). Subgroup analysis showed a consistent direction of effect across randomized and observational studies. The pooled analysis of radiographic non-union showed a non-significant trend favoring PRP (odds ratio: 0.35; 95% confidence intervals: 0.11 – 1.08; p = 0.07; I² = 0%). Complication outcomes were inconsistently reported, and available data did not identify a clear signal of serious PRP-related harm.

CONCLUSION: Heterogeneous PRP-augmented surgical strategies, including PRP gel, platelet concentrate, and composite graft, were associated with a modest reduction in time to radiographic union in lower extremity non-union fractures. Adequately powered trials using standardized PRP protocols and clinically meaningful outcomes are required.

PMID:42562721 | DOI:10.1016/j.cjtee.2026.06.001

Rev Med Interne. 2026 Aug 6:S0248-8663(26)00667-3. doi: 10.1016/j.revmed.2026.07.006. Online ahead of print.

ABSTRACT

OBJECTIVES: Immune-mediated necrotizing myopathy (IMNM) are rare muscular inflammatory muscle diseases that bear poor prognosis. Description of their clinical evolution remains limited in the literature. This study aimed to describe the clinical, biological, and serological features of patients with anti-HMGCR or anti-SRP IMNM presenting with muscle involvement at diagnosis and to identify factors associated with relapse during follow-up.

METHODS: Between January 1st, 2015 and December 31st, 2023, we retrospectively identified 66 patients with anti-3-hydroxy-3-methyl-glutaryl-coenzyme A reductase (HMGCR) or anti-signal recognition particle (SRP) autoantibodies in three French immunology laboratories (Rouen, Le Havre, Dieppe). We included 23 patients with a follow-up of at least 3 months: 14 with anti-HMGCR and 9 with anti-SRP autoantibodies. Statistical analysis was performed on clinical data and focused on a score derived from the manual muscle testing score at 6 months after diagnosis and during follow-up, as well as biological data and treatment strategy.

RESULTS: IMNM patients with anti-SRP were significantly younger and had more severe disease at diagnosis compared to patients with anti-HMGCR. We observed an inverse correlation between creatine kinase (CK) levels and muscular strength during follow-up. At diagnosis, women, anti-SRP patients, and patients who experienced a relapse during follow-up had more severe muscle weakness compared to male, anti-HMCGR positive patients and patients who did not experience a relapse, respectively. Relapse occurred in 65.2% of patients. Relapsing patients had higher CK level and higher anti-SRP levels at diagnosis compared to non-relapsing patients. Treatment with intravenous immunoglobulins was associated with a shorter time to response.

CONCLUSION: Our study provides valuable clinical insights into the management of seropositive IMNM in a real-world setting and highlights the need for further research in this area.

PMID:42562677 | DOI:10.1016/j.revmed.2026.07.006

Heart Lung Circ. 2026 Aug 6:S1443-9506(26)00199-X. doi: 10.1016/j.hlc.2026.01.022. Online ahead of print.

ABSTRACT

BACKGROUND: Aortic angulation (AA), defined as the angle between the horizontal plane on the coronal plane and the plane of the aortic valve annulus, is an important anatomical factor in transcatheter aortic valve replacement (TAVR). Whether AA affects early clinical outcomes and complications in self-expanding (SE)-TAVR procedures is still controversial.

METHOD: We conducted a retrospective cohort study of 519 consecutive patients who underwent SE-TAVR at our centre from January 2016 to January 2021. Preoperative AA, technique success, and one-year postoperative survival rates were primarily analysed.

RESULTS: The AA of patients undergoing SE-TAVR ranged from 25° to 93°, with a mean value of 55.4°±9.7°. There was a statistically significant difference in technique success between AA≤55.5° and AA>55.5° groups (84.3% vs 75.1%, p=0.009), mainly driven by the higher proportion of second-valve implantation during TAVR (8.8% vs 19.6%, p<0.001). In valve-type subgroup analysis, larger AA demonstrated good predictive value for second-valve implantation (area under the curve 0.690; 95% confidence interval 0.617-0.763). However, AA showed limited predictive efficacy for technical success in patients with bicuspid aortic valve, and it was not associated with major complications or unplanned interventions in patients with tricuspid aortic valve.

CONCLUSIONS: A larger AA is associated with a lower rate of technical success of SE-TAVR, mainly due to an increased frequency of second-valve implantation. The impact of AA is more evident in patients with tricuspid aortic valve rather than in those with bicuspid aortic valve.

PMID:42562673 | DOI:10.1016/j.hlc.2026.01.022

An Pediatr (Engl Ed). 2026 Aug 6:504276. doi: 10.1016/j.anpede.2026.504276. Online ahead of print.

ABSTRACT

INTRODUCTION: Breastfeeding (BF) has demonstrated multiple benefits for the mother-infant dyad, including immunological protection for the child. This study assessed the relationship between breastfeeding patterns and morbidity during the first two years of life.

METHODS: We conducted a secondary analysis of data from the LAYDI study. This study was a single-cohort trial to analyze the association between breastfeeding and child development carried out by the Primary Care Pediatric Research Network (PAPenRed) and involving 320 pediatricians. Each pediatrician recruited one newborn per month over one year and followed them up to age 24 months. Demographic, feeding, and morbidity data were collected over seven visits (<15 days, and at 1, 2, 6, 12, 18, and 24 months).

RESULTS: The sample included 2046 infants. We found that BF had a protective effect against common conditions such as constipation in the early visits (P < .001), and against infectious diseases after adjusting for confounders (“having siblings” and “enrolment in child care center”) (P < .001 at 12 and 18 months). Breastfeeding also offered specific protection against the most frequent acute infections, including otitis media, conjunctivitis, bronchiolitis, gastroenteritis, and wheezing episodes, which remained statistically significant after adjustment (P < .005). Exclusive breastfeeding (EBF) through age 6 months conferred long-term protection, particularly against acute otitis media (at 12, 18, and 24 months [P < .001, P < .004, and P < .036]).

CONCLUSIONS: Breastfeeding has a protective effect against common gastrointestinal disorders in infancy (constipation, colic, regurgitation) and against infectious diseases. Exclusive BF in the first 6 months provides sustained protection (12-24 months) against the 19 conditions under study, particularly the most prevalent ones. These results support the association between breastfeeding and reduced morbidity extending through at least the age two years.

PMID:42562657 | DOI:10.1016/j.anpede.2026.504276

J Am Board Fam Med. 2026 Aug;39(1):165305. doi: 10.3122/jabfm.2026.260173R0.

ABSTRACT

BACKGROUND: Virtual scribe services are increasingly utilized to reduce documentation burden and mitigate clinician burnout. While evidence supports their positive impact on clinician wellness and productivity, the effect on patient experience has not received as much attention. We hypothesized that clinicians using virtual scribes would demonstrate improved patient satisfaction scores due to enhanced face-to-face interaction during visits.

METHODS: Using a pre-post design, we analyzed patient satisfaction data for 81 primary care clinicians utilizing asynchronous virtual scribe services (two different vendor programs) within a large integrated health network in Eastern Pennsylvania. Patient satisfaction was measured using four vendor-administered questions assessing overall rating of care, likelihood to recommend, clinician listening, and trust. Pre-implementation scores (6 months prior to scribe utilization) were compared to post-implementation scores (months 3-9 with a scribe service) using related-samples Wilcoxon signed-rank tests.

RESULTS: Statistically significant improvements in patient-reported satisfaction metrics were observed in overall rating of the visit (P < .001) and trust (P = .012). Likelihood to recommend and listening showed positive trends but did not reach statistical significance (P = .086 and P = .705, respectively).

CONCLUSION: Virtual scribe implementation was associated with significant improvements in patient-reported overall experience and trust in their clinicians. These findings suggest that reducing documentation burden may enhance the patient-clinician relationship, providing additional justification for scribe investment beyond clinician wellness.

PMID:42562655 | DOI:10.3122/jabfm.2026.260173R0

J Am Board Fam Med. 2026 Aug;39(1):165727. doi: 10.3122/jabfm.2025.250211R1.

ABSTRACT

OBJECTIVE: Continuity of care with a primary care physician is critical for appropriate healthcare utilization, particularly among seniors with complex health needs. This study examines the association between the length of care continuity and the usual place of care for minor health problems, focusing on emergency department (ED) use.

METHODS: Data were drawn from the 2019-2020 Canadian Health Survey on Seniors (CHSS), a nationally representative 15-minute supplement to the Canadian Community Health Survey (CCHS) for Canadians aged 65 years and older. Of 245,639 selected households, 100,797 individuals responded to the CCHS (41.0%), and 41,635 of 45,863 eligible respondents completed the CHSS (90.8%). Minor health problems or nonurgent conditions were defined as self-reported difficulties accessing immediate care for issues such as fever, vomiting, headaches, sprains, minor burns, cuts, rashes, or other nonlife-threatening conditions. A multinomial logistic regression model examined the association between continuity of care (< 1 year, 1-< 2 years, ≥ 2 years, or no regular provider) and usual place of care, adjusting for demographic, socioeconomic, health, access, and provincial factors.

RESULTS: Among 41,060 seniors, most reported having continuity of care with a primary care physician for two years or more. Males and those reporting poorer health were more likely to use the ED for minor problems, whereas individuals with higher income or education more often sought care at a doctor’s office. Longer continuity of care was associated with lower odds of ED use for minor problems, with consistent effects in both unadjusted (coef. = -0.251, P < 0.001) and adjusted models (coef. = -0.086, P = 0.083). Other determinants, including income, access to care, and province, also influenced care location.

CONCLUSION: Longer continuity with a primary care physician is associated with reduced ED use for minor health problems among seniors. These findings highlight the value of sustained patient-provider relationships in promoting appropriate care utilization and alleviating pressures on emergency departments.

PMID:42562651 | DOI:10.3122/jabfm.2025.250211R1

J Neurointerv Surg. 2026 Aug 6:jnis-2026-025750. doi: 10.1136/jnis-2026-025750. Online ahead of print.

ABSTRACT

BACKGROUND: Flat-detector computed tomography (FDCT) is increasingly used for peri-interventional cerebral imaging but is associated with a relatively high radiation exposure. Copper (Cu) filtration may reduce radiation dose. However, its impact on cerebral image quality and intracranial hemorrhage detection remains unclear.

METHODS: In this retrospective single-center study, 31 patients undergoing neurointerventional procedures with intraindividual FDCT acquisitions with and without Cu filtration were analyzed. Quantitative image quality was assessed using contrast-to-noise ratio (CNR). Qualitative image analysis and intracranial hemorrhage detection were independently evaluated by two readers blinded to Cu filtration status using five-point scales.

RESULTS: Cu filtration resulted in a significant radiation dose reduction of 25.9% for both entrance skin dose (145.19±13.18 mGy vs 195.89±18.05 mGy) and dose-area product (41.52±3.77 Gy·cm² vs 56.01±5.16 Gy·cm²), respectively (P<0.001). No differences in CNR were observed for unfiltered vs Cu-filtered FDCT (basal ganglia: 4.73±2.04 vs 4.37±1.99, P=0.419). Qualitative image ratings were similar between techniques (supratentorial cortex: 2.27±0.66 vs 2.08±0.75, P=0.089), with very good inter-reader agreement (κ=0.86; 95% CI: 0.80 to 0.91). All intracranial hemorrhages were correctly identified by both techniques. Correct exclusion of intracranial hemorrhage was 15/16 with Cu filtration and 14/16 without Cu filtration, without statistically significant difference. Differences were limited to hemorrhage mimics (n=2) and minor variations in diagnostic confidence without affecting binary classification.

CONCLUSION: Cu filtration in cerebral FDCT enables substantial radiation dose reduction while preserving image quality and intracranial hemorrhage detection, supporting its clinical implementation as a practical dose optimization strategy for peri-interventional imaging.

PMID:42562637 | DOI:10.1136/jnis-2026-025750

JACC Adv. 2026 Aug 6;5(9):103015. doi: 10.1016/j.jacadv.2026.103015. Online ahead of print.

ABSTRACT

BACKGROUND: Chronic total occlusion (CTO) is associated with increased ischemic burden, heart failure, and mortality. Comparative clinical outcomes associated with medical therapy, percutaneous coronary intervention (PCI), and coronary artery bypass grafting (CABG) remain uncertain.

OBJECTIVES: To compare clinical outcomes associated with medical therapy, PCI, and CABG in patients with CTO.

METHODS: We analyzed 741 patients with angiographically confirmed CTO enrolled across 7 tertiary centers in 4 Gulf countries between 2021 and 2023. Patients were managed with an initial strategy of medical therapy (n = 151), PCI (n = 441), or CABG (n = 149). The primary in-hospital endpoint was major adverse cardiovascular events. The long-term endpoint was major adverse cardiac and cerebrovascular events-free survival.

RESULTS: Treatment allocation differed substantially by baseline clinical and angiographic risk. Medically managed patients had worse renal function, more severely reduced left ventricular ejection fraction, and more cardiogenic shock despite simpler CTO anatomy CABG patients had more extensive multivessel disease, whereas PCI patients had greater CTO lesion complexity. After adjustment, neither PCI nor CABG differed significantly from medical therapy for in-hospital major adverse cardiovascular events. At a median follow-up of 22 months, adjusted 36-month restricted mean survival time analyses showed no statistically significant difference in major adverse cardiac and cerebrovascular events-free survival between PCI, CABG, and medical therapy. Adjusted Canadian Cardiovascular Society class I at last follow-up was reached in 86.2% of medical therapy, 91.7% of PCI, and 98.0% of CABG patients; the adjusted difference vs medical therapy was significant for CABG (P < 0.001) but not for PCI P = 0.17).

CONCLUSIONS: After adjustment, no treatment strategy demonstrated superiority for hard cardiovascular outcomes; revascularization, particularly CABG, was associated with a lower angina burden at follow-up.

PMID:42561488 | DOI:10.1016/j.jacadv.2026.103015

Gynecol Oncol. 2026 Aug 6;212:57-63. doi: 10.1016/j.ygyno.2026.07.018. Online ahead of print.

ABSTRACT

BACKGROUND: Metastatic cancer patients receiving systemic chemotherapy face increased risks for venous thromboembolism (VTE). Benefit has been shown for prophylactic anticoagulants in risk-stratified populations. Ovarian cancer (OC) is commonly advanced at diagnosis and treated with chemotherapy. Despite high VTE rates among OC patients, predictors of risk in this population are not well studied, and information on the benefit of oral anticoagulants is lacking.

OBJECTIVE: A quality improvement (QI) intervention to improve appropriate anticoagulation in risk-selected OC patients receiving first-line chemotherapy was implemented, prospectively assessing VTE risk reduction.

METHODS: Patients receiving first-line chemotherapy for OC at Sheba Medical Center 2020-2025 were included. A QI program (launched 07/2023) included staff education, EMR-incorporated Khorana scoring, integrated apixaban prescriptions and targeted chemo-suite questionnaires. Data was extracted from the EMR using MDClone® software with Natural Language Processing to identify VTE events in imaging reports. Descriptive statistics were used to compare patients treated before and after program implementation. Predictors of VTE were evaluated with logistic regression.

RESULTS: Patient characteristics were comparable before and after program implementation. VTE rates were high at 16.9% before, and 12.5% following roll-out. No increase in bleeding events or blood products consumption was appreciated. Program implementation was found to be a significant protective factor on multivariable analysis, adjusting for other risk factors (aOR = 0.39 (0.17-0.81), p = 0.015).

CONCLUSION: The implementation of an oral anticoagulation QI program successfully decreased VTE events during first-line chemotherapy for OC with no appreciable increase in risk. Future work will focus on improved risk stratification and selection for thromboprophylaxis.

PMID:42561468 | DOI:10.1016/j.ygyno.2026.07.018

Otol Neurotol. 2026 Aug 6. doi: 10.1097/MAO.0000000000005009. Online ahead of print.

ABSTRACT

BACKGROUND: Hearing restoration by cochlear implantation (CI) yields benefits beyond hearing. Short-term benefits on cognition are well-known, but long-term data are limited and inconsistent. Therefore, we analyzed a large sample of CI recipients with a focus on cognitive changes in the long-term follow-up.

METHODS: Seventy-five CI recipients aged older than or equal to 50 (mean age 65.4, SD 9.2) were tested in attention, immediate and delayed recall, working memory (OSPAN) and verbal fluency (VF) pre-implantation and 12, 24, 54 as well as 99 months post-CI. Three linear mixed-effects models (linear, quadratic, and time-indicator) were fitted and contrasted.

RESULTS: Despite different statistical assumptions, all 3 models converged on initial cognitive improvement after implantation. In the time-indicator model, significant improvements relative to baseline were observed across all 5 outcomes at 12 and 24 months (P<0.01), with effect sizes at 24 months ranging from d=0.26 (OSPAN) to d=0.93 (VF). Subsequent trajectories diverged across domains. At 99 months, only attention (M3) showed sustained improvement (P <0.001, d=0.60), with an effect size comparable to its 24-month peak. The remaining 4 outcomes did not significantly differ from baseline (P>0.05). The quadratic model confirmed inverted-U-shaped trajectories for all outcomes, with significant negative quadratic terms (all P≤0.001).

CONCLUSIONS: Cognitive benefits of cochlear implantation extend beyond the short-term, but long-term trajectories are domain-specific. Considering the multifactorial nature of cognitive aging, multicenter studies with larger sample sizes and extended follow-up visits are needed to clarify the mechanisms behind the impact of CI on cognition.

PMID:42561447 | DOI:10.1097/MAO.0000000000005009