Nevin Manimala

PLoS One. 2025 Jun 3;20(6):e0325150. doi: 10.1371/journal.pone.0325150. eCollection 2025.

ABSTRACT

OBJECTIVE: This meta-analysis investigates the differential risks of suicidal behaviors (ideation, attempts, mortality) associated with current asthma and asthma history.

METHOD: Retrieve cohort studies on the association between asthma and suicide from PubMed, Embase, and Cochrane library database. Use the Newcastle Ottawa Quality Assessment Scale (NOS) to assess the risk of bias. The risk ratio (RR) of 95% confidence interval (CI) was summarized using a random effects model, and publication bias was evaluated using funnel plots and Egger’s trials.

RESULT: A total of 12 cohort studies were included and published between 2005 and 2024. The NOS scores for the 12 cohort studies included in this meta-analysis ranged from 7 to 9. Most studies received scores of 7 or 8, indicating a generally high quality. Current asthma conferred a 62% increased risk of suicidal behaviors (RR = 1.62, 95% CI: 1.38-1.88), with suicide attempts showing the strongest association (RR = 2.27, 95% CI: 1.33-3.89). Asthma history was linked only to elevated suicide mortality (RR = 1.87, 95% CI: 1.64-2.14), not non-fatal suicidal behaviors.

CONCLUSION: Current asthma status is associated with an increased risk of suicidal behaviors, but a history of asthma correlates only with elevated suicide mortality. This finding highlights the need for proactive mental health screening in asthma management protocols, especially during periods of active disease.

PMID:40460338 | DOI:10.1371/journal.pone.0325150

PLoS One. 2025 Jun 3;20(6):e0306587. doi: 10.1371/journal.pone.0306587. eCollection 2025.

ABSTRACT

Muscle-tendon unit (MTU) assessments can be categorised into local (e.g., tendon strain) or global (e.g., jump height) assessments. Although menstrual cycle phase may be a key consideration when implementing these assessments in female athletes, the reliability of many MTU assessments is not well defined within female populations. Therefore, the purpose of this study was to report the test-retest reliability of local and global MTU assessments during the early follicular phase of the menstrual cycle. Seventeen naturally menstruating females (age 28.5 ± 7.3 years) completed local and global MTU assessments during two testing sessions separated over 24-72 hours. Local tests included Achilles’ tendon mechanical testing and isometric strength of ankle plantar flexors and knee extensors, whereas global tests included countermovement, squat, and drop jumps, and the isometric midthigh pull. Based on intraclass correlation coefficient (ICC) statistics, poor to excellent reliability was found for local measures (ICC: 0.096-0.936). Good to excellent reliability was found for all global measures (ICC: 0.788-0.985), excluding the eccentric utilisation ratio (ICC 0.738) and most rate of force development metrics (ICC: 0.635-0.912). Isometric midthigh pull peak force displayed excellent reliability (ICC: 0.966), whereas force-time metrics ranged from moderate to excellent (ICC: 0.635-0.970). Excluding rate of force development (coefficient of variation [CV]: 10.6-35.9%), global measures (CV: 1.6-12.9%) were more reproducible than local measures (CV: 3.6-64.5%). However, local metrics directly measure specific properties of the MTU, and therefore provide valuable information despite lower reproducibility. The novel data reported here provides insight into the natural variability of MTU assessments within female athletes which can be used to enhance the interpretation of other female athlete data, especially that which aims to investigate other aspects of variability, such as the menstrual cycle.

PMID:40460334 | DOI:10.1371/journal.pone.0306587

JCO Clin Cancer Inform. 2025 Jun;9:e2400331. doi: 10.1200/CCI-24-00331. Epub 2025 Jun 3.

ABSTRACT

PURPOSE: Rapid advancements in natural language processing have led to the development of sophisticated language models. Inspired by their success, these models are now used in health care for tasks such as clinical documentation and medical record classification. However, language models are prone to errors, which can have serious consequences in critical domains such as health care, ensuring that their reliability is essential to maintain patient safety and data integrity.

METHODS: To address this, we propose an innovative auditing process based on principles from clinical trial design. Our approach involves subject matter experts (SMEs) manually reviewing pathology reports without previous knowledge of the model’s classification. This single-blind setup minimizes bias and allows us to apply statistical rigor to assess model performance.

RESULTS: Deployed at the British Columbia Cancer Registry, our audit process effectively identified the core issues in the operational models. Early interventions addressed these issues, maintaining data integrity and patient care standards.

CONCLUSION: The audit provides real-world performance metrics and underscores the importance of human-in-the-loop machine learning. Even advanced models require SME oversight to ensure accuracy and reliability. To our knowledge, we have developed the first continuous audit process for language models in health care, modeled after clinical trial principles. This methodology ensures that audits are statistically sound and operationally feasible, setting a new standard for evaluating language models in critical applications.

PMID:40460332 | DOI:10.1200/CCI-24-00331

PLoS One. 2025 Jun 3;20(6):e0324898. doi: 10.1371/journal.pone.0324898. eCollection 2025.

ABSTRACT

BACKGROUND: The last 90 days of life are marked by high healthcare utilization in acute care settings, often conflicting with the preference to remain at home. The COVID-19 pandemic accelerated the adoption of virtual care, but its impact on healthcare utilization near the end-of-life remains unclear. This study assessed the association between physician-delivered virtual care use near the end-of-life and acute healthcare utilization, before and during the COVID-19 pandemic across four Canadian provinces.

METHODS: A retrospective population-based cohort study using linked health administrative data from January 1, 2018, to December 31, 2021, across British Columbia (BC), Alberta (AB), Ontario (ON), and Newfoundland & Labrador (NFLD). The study included 548,955 adult decedents who died within the study period. Virtual care use in the last 90 days of life, categorized by pre-pandemic and pandemic periods, was the primary exposure. Primary outcomes were rates of ED visits, hospitalizations, and in-hospital deaths during the last 90 days of life. Modified Poisson regression models were used to measure associations, adjusting for demographic and clinical characteristics.

RESULTS: Among the 548,955 decedents, virtual care utilization during the pandemic varied by province, ranging from 53% in NFLD to 78% in BC. During the pandemic, virtual care was associated with higher ED visits (adjusted rate ratios [aRateRs] ranging from 1.12 to 1.72) and hospitalizations (aRateRs: ranging from 1.01 to 1.59) in most provinces. Virtual care was linked to a higher risk of in-hospital death in AB (adjusted risk ratios [aRiskR]: 1.11; 95% CI: 1.08-1.14; P < 0.001) and ON (aRiskR: 1.04; 95% CI: 1.03-1.05; P < 0.001). Pre-pandemic, associations were weaker, with virtual care linked to lower in-hospital death rates in ON, AB and BC.

CONCLUSION: Virtual care during the pandemic was linked to increased acute healthcare utilization, contrasting with pre-pandemic patterns when it appeared more selective and associated with fewer in-hospital deaths. Findings highlight the evolving role of virtual care and the need for region-specific policies to optimize end-of-life care delivery.

PMID:40460327 | DOI:10.1371/journal.pone.0324898

JAMA Netw Open. 2025 Jun 2;8(6):e2513285. doi: 10.1001/jamanetworkopen.2025.13285.

ABSTRACT

IMPORTANCE: Integrating artificial intelligence (AI) technologies into gatekeeping holds significant potential, as it efficiently handles repetitive tasks and can process large amounts of information quickly.

OBJECTIVE: To develop and assess the accuracy of an AI model that enhances the gatekeeping process for referrals to specialized care.

DESIGN, SETTING, AND PARTICIPANTS: This diagnostic study comprised referrals from primary care to endocrinology, gastroenterology, proctology, rheumatology, and urology from a retrospective administrative database of patients in Brazil between June 2016 and April 2019. Analysis was performed between December 2022 and July 2024.

MAIN OUTCOMES AND MEASURES: The algorithm’s development and testing comprised 2 stages. Multiple AI models were initially evaluated to train and test the algorithm for categorizing referrals as authorizing or requiring additional information. Subsequently, the model’s performance was assessed against an independent set of referrals. Additionally, the current (human) evaluations of gatekeepers were evaluated against the standard. The reference standard was the consensus of 2 physicians with extensive experience. Accuracy, sensitivity, specificity, and area under the receiver operating characteristic curve (AUC-ROC) were assessed.

RESULTS: The electronic system retrieved 45 039 eligible referrals for the development stage (mean [SD] patient age, 51.9 [15.8] years; 25 458 women [56.5%]). An algorithm utilizing word embeddings and a neural network proved the most effective. In the second phase, 1750 referrals (350 for each specialty) showed a 32% authorization rate according to the reference standard. The AI model achieved an overall accuracy of 0.716 (95% IC, 0.694-0.737), with a sensitivity of 0.542 (95% CI, 0.501 to 0.582) and specificity of 0.801 (95% CI, 0.777 to 0.822). Regarding individual specialties, rheumatology exhibited the highest accuracy (0.811; 95% IC, 0.767-0.849), while proctology had the lowest (0.649; 95% IC, 0.597-0.697). The overall AUC-ROC was 0.765 (95% IC, 0.742-0.788). When compared against the consensus standard, the AI model had higher accuracy and specificity and lower sensitivity than the current approach.

CONCLUSIONS AND RELEVANCE: In this diagnostic study of referral data, a novel AI model effectively distinguished between referrals that warranted immediate authorization and those that required further information with moderate accuracy; it had higher specificity and lower sensitivity than gatekeepers decisions. Implementing this AI model in the gatekeeping process should combine human judgment and AI support to optimize the referral process.

PMID:40459894 | DOI:10.1001/jamanetworkopen.2025.13285

JAMA Netw Open. 2025 Jun 2;8(6):e2513366. doi: 10.1001/jamanetworkopen.2025.13366.

ABSTRACT

IMPORTANCE: Transcatheter closure of the patent ductus arteriosus (PDA) has increasingly been adopted in extremely preterm infants as a method to definitively close the PDA while avoiding the inherent risks of surgical ligation. Differences in respiratory outcomes after transcatheter closure compared with surgical ligation have not been substantiated, particularly in the context of timing of the intervention.

OBJECTIVE: To characterize respiratory outcomes in extremely preterm infants with PDA treated with transcatheter device closure compared with surgical ligation.

DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study assessed data from preterm infants born at less than 29 weeks’ gestation or with birth weight less than 1000 g who underwent definitive PDA closure in neonatal intensive care units participating in the Neonatal Research Network’s Generic Database between January 1, 2016, and December 31, 2020. Data were analyzed from October 2021 to February 2024.

EXPOSURES: PDA treatment with transcatheter device closure or with surgical ligation.

MAIN OUTCOMES AND MEASURES: The primary outcome was total days of mechanical ventilation.

RESULTS: Of 3806 included infants with a PDA diagnosis, 202 underwent transcatheter PDA closure (median [IQR] gestational age, 25.4 [24.1-27.1] weeks; 114 [56%] female) and 359 underwent surgical ligation (median [IQR] gestational age, 24.9 [24.0-25.9] weeks; 187 [52%] female). Infant age at transcatheter closure was older than at surgical ligation (mean [SD], 58.7 [28.4] vs 33.6 [16.7] days; P < .001). After adjustment of analyses for center, birth year, gestational age, age at PDA intervention, and prior pharmacologic treatment, infants with transcatheter closure compared with surgical ligation had comparable respiratory outcomes, including total days of mechanical ventilation (adjusted median difference, -2.65 [95% CI, -8.36 to 3.07] days; P = .36).

CONCLUSIONS AND RELEVANCE: In this cohort study of extremely preterm infants who underwent transcatheter closure compared with surgical ligation for treatment of PDA, respiratory outcomes did not differ, although the transcatheter closure group had a longer duration of PDA exposure. Future research evaluating outcomes after transcatheter PDA closure should assess the optimal timing of definitive intervention.

PMID:40459893 | DOI:10.1001/jamanetworkopen.2025.13366

JAMA Netw Open. 2025 Jun 2;8(6):e2513394. doi: 10.1001/jamanetworkopen.2025.13394.

ABSTRACT

IMPORTANCE: The role of supplemental coverage (eg, Medigap) in Medicare enrollment and disenrollment is understudied among beneficiaries with cancer. Understanding the association between initially selecting a supplement and switching plans is necessary to ensure adequate and affordable coverage for beneficiaries with high-cost health conditions.

OBJECTIVE: To evaluate Medicare plan switching by initial plan selection and history of cancer.

DESIGN, SETTING, AND PARTICIPANTS: This cohort study used data from the Health and Retirement Study, from 2008 to 2020. Respondents were aged 65 or 66 years at initial Medicare plan selection and completed 2 consecutive surveys. Analyses were conducted from November 2023 to October 2024.

EXPOSURES: Self-reported initial Medicare plan selection (traditional Medicare [TM] without supplemental coverage, TM plus supplemental coverage, or Medicare Advantage [MA]) and history of cancer.

MAIN OUTCOMES AND MEASURES: The primary outcome was self-reported Medicare plan switching in the 2 years after initial plan selection. Modified Poisson regression was used to assess the association between initial Medicare plan selection and plan switching. Models adjusted for baseline sociodemographic and health-related characteristics and were stratified by a history of cancer.

RESULTS: Among 2852 respondents aging into Medicare (1113 male [39.02%]), 1511 (52.98%) initially selected TM plus supplemental coverage and 358 (12.55%) reported a history of cancer. Less than one-third of beneficiaries (786 beneficiaries without a history of cancer [31.52%] and 106 beneficiaries with a history of cancer [29.61%]) switched coverage in the 2 years after initial plan selection. Most beneficiaries switched from TM without supplemental coverage to benefits with greater financial protections; 131 of 227 beneficiaries without a history of cancer (57.71%) switched to MA, and 18 of 27 beneficiaries with a history of cancer (66.67%) switched to TM plus supplemental coverage. Among beneficiaries without a history of cancer, initial selection of MA (adjusted risk ratio [aRR], 0.55; 95% confidence limit [CL], 0.47-0.64) or TM plus supplemental coverage (aRR, 0.63; 95% CL, 0.55-0.72) was associated with a lower probability of switching coverage compared with initial selection of TM without supplemental coverage. Findings were similar for beneficiaries with a history of cancer.

CONCLUSIONS AND RELEVANCE: In this cohort study of older adults with and without a history of cancer, initial selection of MA or TM plus supplemental coverage was associated with a low likelihood of switching coverage. Given that benefits with greater financial protections may meet beneficiaries’ evolving needs and preferences, policymakers should consider improving the adequacy of TM.

PMID:40459892 | DOI:10.1001/jamanetworkopen.2025.13394

JAMA Netw Open. 2025 Jun 2;8(6):e2513527. doi: 10.1001/jamanetworkopen.2025.13527.

ABSTRACT

IMPORTANCE: National statistics about regionalization and access to hospitals’ pediatric services have been derived from different datasets with differing sampling frames, sizes, and designs, generating conflicting estimates about pediatric service accessibility.

OBJECTIVE: To calculate test characteristics for the provision of pediatric hospital-based inpatient services in 3 national datasets and explore models for improving service identification in a merged dataset.

DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study analyzed pediatric services in 3114 US hospitals common across the American Hospital Association Annual Survey (AHA), Centers for Medicare & Medicaid Services Provider of Service File (POS), and National Pediatric Readiness Project (NPRP) in 2021. Analysis was conducted June 2024 to March 2025.

EXPOSURE: Provision of 4 pediatric services-newborn, neonatal intensive care, general pediatric inpatient care, and pediatric intensive care.

MAIN OUTCOMES AND MEASURES: Test characteristics and model performance were calculated and reported as F1 scores, a machine learning evaluation metric that calculates the harmonic mean of precision and recall within a model, for the provision of services as reported in the AHA and POS relative to the NPRP, this study’s benchmark for pediatric service reporting. Logistic regression, random forest, gradient-boosted trees, and rule-based models were tested to estimate pediatric service provision using a merged dataset.

RESULTS: Of 3114 hospitals, NPRP identified 2742 providing newborn care (88.1%), 1375 with neonatal intensive care (44.2%), 2204 offering general pediatric care (70.8%), and 450 with pediatric intensive care (14.5%). For newborn care, AHA data showed 95.7% agreement with NPRP (F1 = 0.97; 95% CI, 0.96-0.97), while POS showed 89.4% (F1 = 0.62; 95% CI, 0.60-0.64). For neonatal intensive care, agreement was 89.8% for AHA (F1 = 0.86; 95% CI, 0.85-0.88) and 72.9% for POS (F1 = 0.75; 95% CI, 0.74-0.77). General pediatric care showed lower agreement, with AHA showing 65.6% agreement (F1 = 0.69; 95% CI, 0.67-0.71) and POS showing 69.7% agreement (F1 = 0.79; 95% CI, 0.77-0.80). For pediatric intensive care, AHA agreement was 81.5% (F1 = 0.91; 95% CI, 0.90-0.93) while POS was 78.3% (F1 = 0.49; 95% CI, 0.46-0.51). Merging datasets modestly improved service identification accuracy.

CONCLUSIONS AND RELEVANCE: In this cross-sectional study of commonly used datasets, reporting of pediatric service provision varied significantly. As these datasets inform pediatric health care policy, these results may guide approaches to optimize service line definitions.

PMID:40459891 | DOI:10.1001/jamanetworkopen.2025.13527

JAMA Netw Open. 2025 Jun 2;8(6):e2513537. doi: 10.1001/jamanetworkopen.2025.13537.

ABSTRACT

IMPORTANCE: The US has the highest incarceration rates in the developed world. The harms of incarceration have long-term health implications, including increased mortality. Existing studies of incarceration-related mortality are limited by data sources and design.

OBJECTIVE: To examine the associations between both individual- and area-level incarceration rates with all-cause and overdose mortality in the US.

DESIGN, SETTING, AND PARTICIPANTS: This cohort study used data from the Mortality Disparities in American Communities (MDAC) study, linking over 3 million 2008 American Community Survey (ACS) respondents to National Death Index data from the respondents’ 2008 interview date through December 31, 2019, or their date of death, and county incarceration data from the Vera Institute of Justice. The sample included US adults 18 years or older, representing individuals in group quarters such as prisons and jails but excluding those in counties lacking jail incarceration rate data. Data were analyzed from July 5, 2023, to November 10, 2024.

EXPOSURE: Individual incarceration status at the time of the ACS survey and county jail incarceration rates.

MAIN OUTCOMES AND MEASURES: The outcomes of interest were all-cause mortality and overdose mortality, assessed through time-to-event analyses. Cox proportional hazard models were used to estimate mortality risks, adjusting for individual- and county-level characteristics. ACS survey weights were applied so that the final sample represents the US adult population.

RESULTS: The study includes a total of 3 255 000 individuals (51.3% female), of whom 45 000 (0.93%) were incarcerated at the time of the 2008 ACS administration. The mean (SD) county jail incarceration rate was 372 (358) per 100 000 people. During the study period, 431 000 individuals (11.6%) died from any cause, and 5500 (0.2%) died from overdoses. Incarcerated individuals had a higher risk of all-cause mortality (hazard rate [HR], 1.39 [95% CI, 1.33-1.45]) and an increased risk of overdose mortality (HR, 3.08 [95% CI, 2.70-3.52]) compared with nonincarcerated individuals. A 10% increase in county jail incarceration rates was associated with 4.6 (95% CI, 3.8-5.5) additional all-cause deaths per 100 000 people.

CONCLUSIONS AND RELEVANCE: In this cohort study of 3.26 million individuals in the US, results highlighted the dual burden of incarceration on health outcomes. Individuals who were incarcerated faced significantly higher risks of death, particularly from overdoses, and elevated county incarceration rates exacerbated individual-level mortality risks. These findings suggest the need for reforms in criminal justice and public health policies to address these elevated risks and their widespread implications.

PMID:40459890 | DOI:10.1001/jamanetworkopen.2025.13537

JAMA Netw Open. 2025 Jun 2;8(6):e2513578. doi: 10.1001/jamanetworkopen.2025.13578.

ABSTRACT

IMPORTANCE: Given that nearly one-third of US births are cesarean deliveries, subsequent births after a cesarean delivery are common. Racial and ethnic disparities in severe maternal morbidity (SMM) have been well-documented, and prior studies have identified differences in birth mode after prior cesarean delivery by race and ethnicity.

OBJECTIVE: To examine variation by race and ethnicity in the association between SMM and birth mode for individuals with a prior cesarean delivery.

DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study used Massachusetts linked birth certificate and hospital discharge data from 2012 to 2021. The analytic sample was limited to births to individuals with 1 prior cesarean delivery. Data were analyzed from August 23, 2024, to March 31, 2025.

EXPOSURES: Race and ethnicity and birth mode (vaginal birth after cesarean delivery, planned repeat cesarean delivery, and unplanned repeat cesarean delivery).

MAIN OUTCOME AND MEASURES: SMM was measured using Centers for Disease Control and Prevention indicators. Associations of race and ethnicity and birth mode with SMM were calculated using logistic regression, then an interaction term was added between race and ethnicity and birth mode. Models controlled for covariates.

RESULTS: The study population included 72 836 individuals (mean [SD] age, 32.40, [5.03] years), of whom 8022 (11.0%) were Black, 14 664 (20.1%) were Latinx, and 41 350 (56.8%) were White. Approximately one-third of individuals were born outside the US (25 119 individuals [34.5%]). In adjusted analyses, Black individuals had higher odds of SMM compared with White individuals (adjusted odds ratio [AOR], 1.60; 95% CI, 1.25-2.05). Odds of SMM were higher for unplanned repeat cesarean birth (AOR, 3.05; 95% CI, 2.23-4.18) compared with vaginal birth after cesarean delivery, and higher for planned repeat cesarean birth compared with vaginal birth after cesarean delivery (AOR, 1.57; 95% CI, 1.20-2.06). Including an interaction term identified variation in the association between birth mode and SMM by race and ethnicity. Planned repeat cesarean birth vs VBAC was associated with an increase in the likelihood of SMM of 0.56 (95% CI, 0.21-0.90) percentage points (P = .001) among Black birthing people and 0.46 (95% CI, 0.16-0.76) percentage points (P = .003) among Latinx birthing people, while among White individuals, the likelihood of SMM did not differ between planned repeat cesarean birth and VBAC.

CONCLUSIONS AND RELEVANCE: In this cross-sectional study of births among individuals with a prior cesarean birth, patterns of SMM by birth mode varied by race and ethnicity, with elevated rates of SMM among those from marginalized racial and ethnic groups with planned cesarean births. Future work should identify interventions to improve quality of care and promote equity for this population.

PMID:40459888 | DOI:10.1001/jamanetworkopen.2025.13578