Nevin Manimala

JMIR Form Res. 2025 Aug 19;9:e73078. doi: 10.2196/73078.

ABSTRACT

BACKGROUND: Disaster telehealth can be used to provide rapid access to remote specialty expertise and virtual surge capacity for overwhelmed local clinicians. The Regional Disaster Health Response System (RDHRS) is developing a disaster teleconsultation system for cross-jurisdictional care in the United States. In 2020, the Region 1 RDHRS provided Massachusetts hospitals access to disaster teleconsultation services with out-of-state critical care experts during the first wave of the COVID-19 pandemic response.

OBJECTIVE: We aimed to field-test (1) the acceptability and feasibility of using a prototype, web-based disaster teleconsultation platform with minimal-to-no user training and (2) the feasibility of deploying a national volunteer expert pool to access out-of-state expertise.

METHODS: This was a prospective, mixed methods, observational study. We recruited field clinicians from Massachusetts hospitals and out-of-state critical-care physicians as experts for a 2-week pilot (June 2020). Experts were trained to use a prototype platform, while field clinicians received a just-in-time tool. Field clinicians requested teleconsultations for hospitalized patients with COVID-19 (clinical call) or simulated patients (test call). We collected demographics, call performance data, and Telehealth Usability Questionnaire (TUQ) ratings to measure acceptability (primary outcome; total usability score ≥6 of 7) and feasibility (secondary outcome; interface, interaction quality, and reliability items), and interviewed participants. We report descriptive statistics and key themes using the Technology Acceptance Model framework.

RESULTS: Ten experts from 6 states and 17 field clinicians from 4 hospitals participated. All experts and 10 field clinicians completed postpilot questionnaires (74% response overall). Of these, 20% had previously used telemedicine in a disaster. In total, 50 test calls and no clinical calls were logged. Most (70%) made ≥1 call; 22% (95% CI 10%-34%) connected successfully. The median time to connect was 1.6 (IQR 3.2) minutes. Among field clinician respondents, 50% used smartphone devices, 40% hospital desktop computers, and 10% laptop computers to access RDHRS teleconsultation services. Calls failed due to platform routing errors (49%), hospital computers without cameras or microphones (10%), firewalls (8%), and expert notification failures (5%). The mean total usability score was 5.6 (SD 1.3). TUQ item scores were highest in usefulness (mean 6.0, SD 1.1) and ease-of-use (mean 6.0, SD 1.4), and lowest in reliability (mean 2.4, SD 1.4). Participants were comfortable using the platform. Those with difficulty identified discomfort with technology as the cause. All experts were willing to participate in a national expert registry and obtain emergency licensure, and most (80%) were willing to serve on a volunteer, unpaid basis.

CONCLUSIONS: Clinicians found the prototype platform acceptable, but the workflow requires revision to reduce call failure and improve feasibility and reliability for future use with minimal-to-no training. Using familiar clinical workflows for emergency consultation and mobile devices with camera and microphone capabilities could improve call performance and reliability.

PMID:40829123 | DOI:10.2196/73078

Neurology. 2025 Sep 9;105(5):e213996. doi: 10.1212/WNL.0000000000213996. Epub 2025 Aug 19.

ABSTRACT

BACKGROUND AND OBJECTIVES: While preclinical studies documented potential neuroprotective effects of estrogen/progesterone, the impact of biological sex on outcomes after traumatic spinal cord injury (tSCI) remains incompletely understood. The aim of this study was to compare male and female age-stratified subgroups, which presumably correspond to premenopausal, perimenopausal, and postmenopausal states, concerning access to optimal care and their outcomes after tSCI.

METHODS: A series of propensity score-matched cohort studies was performed, comparing female individuals with male individuals in the younger (age≤ 40 years), middle-aged (41-50 years), and older (>50 years) subgroups regarding baseline data; management strategies; access to optimal care; and hospital, neurologic, and functional outcomes after tSCI. Data were selected from 5,571 individuals with tSCI at C1-L2 who were enrolled in the Rick Hansen Spinal Cord Injury Registry from July 2004 to September 2019. Outcome measures included in-hospital mortality and motor and sensory score changes from admission to an acute care hospital to discharge from a rehabilitation center.

RESULTS: In the younger subgroups, female individuals (n = 320, mean age: 26 years) were more often White and had a greater proportion of tSCIs due to falls or transportation-related accidents than male individuals (n = 320, mean age: 26.5 years). Younger female and male subgroups had similar in-hospital mortality rates (0.6% vs 0.6%, p = 1) and motor (4 vs 5, p = 0.8919) and sensory (2 vs 5, p = 0.5) score changes after tSCI. In the middle-aged subgroups, female individuals (n = 133, mean age: 46 years) and male individuals (n = 113, mean age: 46 years) had statistically comparable baseline data, in-hospital mortality rates (2.3% vs 3.0%, p = 1), and motor (12 vs 5, p = 0.8766) and sensory (0 vs 2, p = 0.4918) score changes. In the older subgroups, female individuals (n = 531, mean age: 68 years) showed a higher frequency of fall-related tSCI but they had similar in-hospital mortality rates (7.7% vs 9.8%, p = 0.2324) and motor (9 vs 8, p = 0.7594) and sensory (5 vs 0, p = 0.7204) score changes after tSCI compared with male individuals (n = 531, mean age: 68 years).

DISCUSSION: The results of this study suggest that biological sex does not significantly affect in-hospital mortality and neurologic recovery after tSCI when optimal care is applied, according to data from a Canadian registry. Those findings support the notion that sex equity in management strategies promotes equal outcomes after tSCI.

PMID:40829102 | DOI:10.1212/WNL.0000000000213996

Neurology. 2025 Sep 9;105(5):e213975. doi: 10.1212/WNL.0000000000213975. Epub 2025 Aug 19.

ABSTRACT

BACKGROUND AND OBJECTIVES: Higher white matter hyperintensity volume (WMHV) is associated with hippocampal atrophy, cognitive decline, and dementia; however, it is unknown whether continually increasing WMHV is related to hippocampal atrophy. The aim of this study was to determine whether higher WMHV change rate (WMHVR) is related to higher hippocampal atrophy rate (HAR); this relationship is dependent on cardiovascular risk factors (CVRFs), Alzheimer disease (AD) pathology, and genetic risk; and this relationship is mediated by neuroaxonal degradation.

METHODS: Participants from Insight46, a substudy of the 1946 British Birth Cohort, underwent combined [¹⁸F]florbetapir PET/MRI scans at University College London approximately 2.5 years apart. WMHVR was quantified from T2/fluid-attenuated inversion recovery and HAR from T1 sequences. Life-course blood pressure and CVRF data were measured at 6 and 3 time points, respectively. APOE genotype and neurofilament light chain (NfL) quantification were derived from blood samples. Participants with neurologic conditions were excluded from primary analyses. Linear regression was used to test the relationships between WMHVR and HAR, adjusting for sex, age, and total intracranial volume (TIV) and CVRF, APOE-ε4 status, and β-amyloid (Aβ) in separate models. Semipartial R² was calculated from these models. In a post hoc analysis, structural equation modeling aimed to determine whether NfL mediated the relationship between WMHVR and HAR.

RESULTS: A total of 317 individuals without neurologic conditions (48% female, 100% White British, mean baseline age [SD] = 70.5 [0.6] years) were included. The mean HAR was 0.04 [0.04] mL/y. Each 1 mL/y increase in WMHVR was associated with a 0.014 mL/y (95% CI 0.005-0.022) increase in HAR, adjusted for TIV, age, and sex (p = 0.002). Adjustment for additional variables did not meaningfully attenuate this association (≥0.012 mL/y, p ≤ 0.005, all models), and there was no indirect effect through NfL (0.0004 mL/y [95% CI -0.0006 to 0.0012], p < 0.1).

DISCUSSION: Higher WMHVR was associated with HAR between approximately 70 and 73 years, independent of CVRF levels, APOE-ε4 status, and Aβ load, and not mediated by markers of neuroaxonal degradation. Although AD-specific pathology is typically considered the main cause of accelerated HAR, we demonstrated that HAR is also linked to deteriorating WM health. These results will need to be replicated in more diverse cohorts with longer follow-up periods to confirm the findings.

PMID:40829101 | DOI:10.1212/WNL.0000000000213975

Am J Manag Care. 2025 Aug 1;31(8):e238-e240. doi: 10.37765/ajmc.2025.89780.

ABSTRACT

OBJECTIVE: To assess trends in assigned International Statistical Classification of Diseases, Tenth Revision ( ICD-10 ) codes for patients hospitalized with heart failure (HF) from 2018 to 2022 in 2 large US health systems.

STUDY DESIGN: Retrospective cross-sectional analysis of ICD-10 codes assigned to patients hospitalized with HF in the Providence Health and University of Colorado Health (UCHealth) systems.

METHODS: The study included patients discharged from the Providence Health and UCHealth systems between 2018 and 2022 with a primary diagnosis of HF. ICD-10 codes analyzed included systolic HF (I50.2), diastolic HF (I50.3), combined systolic and diastolic HF (I50.4), hypertensive heart disease with HF (I11.0), and hypertensive heart disease with HF and chronic kidney disease (CKD) (I13.0, I13.2). Hospitalization data were analyzed separately for each health system due to privacy policies.

RESULTS: Between 2018 and 2022, 61,238 HF hospitalizations occurred in the Providence Health system, and 13,576 occurred in UCHealth. Hypertensive heart disease with HF and CKD was the most common diagnosis, accounting for 42% to 56% of HF hospitalizations, followed by hypertensive heart disease with HF (34%-42%). Together, these diagnoses represented 85% to 90% of HF hospitalizations. Systolic, diastolic, and combined HF codes accounted for only 9% to 18% of hospitalizations. Significant variability in hypertension prevalence (ie, 100% in Providence Health and 38%-39% in UCHealth) was observed between the 2 health systems in patients with codes I13.0 and I13.2.

CONCLUSIONS: The study highlighted a significant shift in HF diagnosis codes, with hypertensive heart disease with HF with and without CKD now predominant. The findings highlight the need for standardized coding practices across health systems for quality improvement initiatives and health services research.

PMID:40829099 | DOI:10.37765/ajmc.2025.89780

Mil Med. 2025 Aug 19:usaf407. doi: 10.1093/milmed/usaf407. Online ahead of print.

ABSTRACT

INTRODUCTION: The Defense Health Agency directs that military Medical Treatment Facilities provide Patient-Centered Medical Home (PCMH) services within its Internal Medicine and other Primary Care clinics. Development and documentation of self-management goals for chronic diseases within the electronic medical record (EMR) is a PCMH accreditation standard through the Joint Commission. This quality improvement project aimed to implement a structured approach to creating and documenting SMART (Specific, Measurable, Achievable, Relevant, and Time-bound) goals for patients with Type 2 Diabetes Mellitus (DM) in a military-affiliated Internal Medicine clinic. Although SMART goals have demonstrated clinically meaningful reductions in hemoglobin A1c (HbA1c), the effects of SMART goals on patient perceptions of their health and self-management of their DM have not been fully studied.

MATERIALS AND METHODS: This study voluntarily enrolled 62 patients aged 19-90 with DM and HbA1c >8% (64 mmol/mol) within the previous 6-month period from a military-affiliated Internal Medicine clinic. Exclusion criteria included patients following with a subspecialist for DM management. Enrolled patients developed and discussed SMART goals with their physician using a standardized goal-setting tool for self-management of their DM. These goals were documented in the EMR for longitudinal follow-up between patients, physicians, and the clinic care team. HbA1c and patient self-reported health perceptions were evaluated before and after 3 months of participation in this intervention. Data analysis used a 2-tailed paired samples t-test. The study protocol underwent Institutional Review Board examination and was determined not to constitute research.

RESULTS: Of 62 patients enrolled, 36 completed post-surveys and were included in the statistical analysis. Results showed a statistically significant reduction in HbA1c levels, with a mean decrease from 9.18% (77.2 mmol/mol) to 7.84% (62.7 mmol/mol) (P < 0.001). Patient-reported perceptions of their health, goal-oriented behaviors, perceived ability to influence health through lifestyle changes, and responsibility for self-management of their DM did not change significantly.

CONCLUSIONS: This quality improvement project further highlights the importance of self-management goals in improving biomedical outcomes and disease management markers. Despite a significant improvement in HbA1c, no changes were observed in patient-reported health perceptions. Overall, patients indicated high adherence and positive feedback with this intervention. The goal-setting tool and standardized documentation strategy as implemented are a viable strategy for satisfying a PCMH accreditation standard. Future studies could address limitations such as single-site design, response rates, and review specific effects on perceptions with the use of validated survey instruments. Similar self-management interventions can be applied to other chronic diseases where daily lifestyle choices influence outcomes.

PMID:40829048 | DOI:10.1093/milmed/usaf407

Chaos. 2025 Aug 1;35(8):083127. doi: 10.1063/5.0279141.

ABSTRACT

We develop a rigorous mathematical framework to determine the optimal inter-layer edge configurations that maximize synchronizability in two-layer chain networks-an area previously limited to empirical approaches. Departing from prior work relying on numerical simulations, we analytically prove that synchronizability is maximized when inter-layer edges are placed (i) at the chain’s midpoint (single-edge case) and (ii) at the one-quarter and three-quarter positions (dual-edge case). We also compute the coupling strength thresholds and further conjecture the optimal placement pattern for an arbitrary number of inter-layer edges, supporting this hypothesis with extensive numerical validation. These results bridge spectral graph theory and network topology design, offering principled guidelines for engineering interconnected chain-like systems, such as supply chains, information dissemination, and epidemic spread.

PMID:40829032 | DOI:10.1063/5.0279141

Am J Audiol. 2025 Aug 19:1-17. doi: 10.1044/2025_AJA-25-00066. Online ahead of print.

ABSTRACT

PURPOSE: The Minimum Speech Test Battery-Version 3 for adults (MSTB-3) was released in 2024 as an evidence-based, streamlined test battery for pre-operative determination of candidacy and postoperative assessment of adult cochlear implant (CI) performance. A survey was dispersed to examine clinicians’ understanding and adoption of the new protocol and gain clinical insights on its implementation.

METHOD: A link to a 32-question survey was distributed to audiologists via e-mail and social media platforms, collecting responses from 307 participants practicing in various settings. The survey assessed respondents’ understanding of MSTB-3 materials, participation in training sessions, and integration of MSTB-3 recommendations into clinical care. Descriptive statistics were used to analyze data and identify trends.

RESULTS: Results indicated that 89% of audiologists were familiar with the MSTB-3, with 60% having participated in one or more training sessions. Of the respondents, 85% reported incorporating parts or all of the MSTB-3 recommendations into their practices and 75% believed it improved standardization of CI evaluations. Clinicians reported using Consonant-Nucleus-Consonant (CNC) word scores for CI candidacy decisions, consistent with MSTB-3 recommendations, but varied in the score criteria used to determine candidacy. Results show a trend toward more streamlined and efficient patient care delivery recommendations.

CONCLUSIONS: The MSTB-3 has facilitated greater consistency in CI evaluation and follow-up care, addressing historical variability in clinical practices. Its evidence-based approach, including streamlined test protocols and user-friendly tools, offers a framework for improved CI access and standardization. Further training and dissemination efforts are recommended to enhance clinicians’ understanding and to address implementation challenges, ultimately advancing the quality of CI services and reducing disparities in care.

PMID:40829022 | DOI:10.1044/2025_AJA-25-00066

Pediatr Infect Dis J. 2025 Aug 6. doi: 10.1097/INF.0000000000004939. Online ahead of print.

ABSTRACT

BACKGROUND: Streptococcus pneumoniae (Spn) and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are important pathogens. We evaluated the frequency and density of Spn in nasopharyngeal samples, frequency of multiple respiratory virus detection, mucosal cytokine/chemokine levels, and mucosal antibody levels to Spn proteins and capsular polysaccharides during SARS-CoV-2 respiratory infections in children.

METHODS: This retrospective study evaluated 222 nasopharyngeal samples collected from children (age 0-18 years) who were tested for SARS-CoV-2 between May 2020 and October 2021. In 111 SARS-CoV-2 positive (+) and 111 SARS-CoV-2 negative (-) samples, we tested for Spn presence and density, 6 viruses (influenza, parainfluenza, respiratory syncytial virus, human rhinovirus, enterovirus and adenoviruses), 9 mucosal cytokine and chemokine levels, mucosal immunoglobulin G (IgG) and IgA antibody levels to Spn PhtD and PcpA proteins and 7 capsular polysaccharides.

RESULTS: Fourteen percent had Spn concurrently present in SARS-CoV-2+ versus 10.6% for SARS-CoV-2-, (not significant). Concurrent SARS-CoV-2 and human rhinovirus detection occurred. Nasopharyngeal cytokine levels in SARS-CoV-2+ samples were not different compared to SARS-CoV-2- samples, except for monocyte chemoattractant protein-1 (higher in SARS-CoV-2+), and not impacted by presence/density of Spn. Nasopharyngeal IgG antibody levels to PhtD and PcpA, and capsular polysaccharide serotypes during SARS-CoV-2+ infections were not different compared to SARS-CoV-2-.

CONCLUSION: Nasopharyngeal Spn detection and density were not different between SARS-CoV-2+ and SARS-CoV-2- samples in children. Concurrent respiratory virus infection was not common. Nasopharyngeal monocyte chemoattractant protein-1 was higher in SARS-CoV-2+ children. Nasopharyngeal IgG antibody levels to 2 Spn proteins and 7 polysaccharide capsule types did not differ between SARS-CoV-2+ and SARS-CoV-2- samples.

PMID:40829009 | DOI:10.1097/INF.0000000000004939

Int J Periodontics Restorative Dent. 2025 Aug 19;0(0):1-27. doi: 10.11607/prd.7814. Online ahead of print.

ABSTRACT

In subepithelial connective tissue graft (SCTG) harvesting, some clinicians prefer to leave the periosteum at the donor site, anticipating faster healing of the palatal wound, though this assumption has not been clinically proven yet. This study aimed to compare early wound healing at palatal donor sites and patient-reported outcome measures (PROMs: pain perception, delayed bleeding and sensation loss) after harvesting SCTG with or without periosteum using the single-incision technique (SIT). Thirty-eight patients were randomly assigned to two groups: SCTG with periosteum (SCTGP+ group) and SCTG without periosteum (SCTGP- group). Assessment of donor site wound healing at one-week post-surgery using modified early healing index (EHI) was the primary outcome of the study and PROMs were the secondary outcomes. Thirty-four patients (17 in each group) were included in final analysis. The mean EHI for SCTGP+ group (2.88 ± 1.22) and for SCTGP- group (2.70 ± 1.10) did not differ significantly (p = 0.661). Palatal flap thickness was found to be negatively correlated with EHI (p < 0.001) and pain (p < 0.05). No statistically significant differences in pain perception were observed between the groups at any time point. None of the patients reported delayed bleeding. Sensation loss recovery was faster in SCTGP+ group with significant difference between the groups only at week 2 (p = 0.026). Within the limitations of our study, harvesting of SCTG with or without periosteum was not found to significantly influence the wound healing and pain perception at palatal donor site.

PMID:40829008 | DOI:10.11607/prd.7814

Traffic Inj Prev. 2025 Aug 19:1-11. doi: 10.1080/15389588.2025.2538725. Online ahead of print.

ABSTRACT

OBJECTIVE: Pre-crash injury risk prediction is crucial for proactive safety measures, while traditional models, which output single-point predictions without explaining the decision reasons, often lack interpretability and reliable uncertainty estimation to reflect potential risk distributions. These drawbacks limit their practical effectiveness in mitigating injury severity. To overcome these limitations, this study develops a novel framework that outputs potential risk distributions and their corresponding probabilities using only pre-crash data, thereby delivering probabilistic outputs with a statistically guaranteed 90% confidence level. By introducing such a framework, we aim to provide a more convincing and interpretable analysis of the injury distribution and its underlying causes in traffic accidents, ultimately offering data-driven guidance for injury mitigation strategies.

METHODS: Data from the National Automotive Sampling System-Crashworthiness Data System and the Crash Investigation Sampling System were used, incorporating 28 pre-crash risk factors. Several machine learning models, including ensemble methods and the deep learning model TabNet, were evaluated. To address the significant class imbalance, particularly the limited number of serious injury cases, various resampling strategies were applied. The core contribution lies in integrating conformal prediction methods, both naive and class-conditional, to generate prediction sets at a 90% confidence level. Model performance was assessed via global evaluation metrics (i.e., f1-score) and serious injury recall, and interpretability was enhanced using explainable machine learning and statistical analysis.

RESULTS: Comparative experiments indicate a nearly 90% prediction coverage and a 70.3% recall rate for serious injuries by proposed framework, which is significantly higher than those reported in related studies. Further model interpretation highlights key risk factors such as intersection relevance, crash type, and speed limits and how they effect injury severity prediction.

CONCLUSIONS: Proposed framework demonstrates significant potential in pre-crash injury risk prediction by introducing conformal prediction techniques to machine learning models. In addition to enhancing predictive performance to nearly 90% prediction coverage and a 70.3% recall rate for serious injuries, this framework also provides enhanced interpretability by quantifying prediction uncertainty and identifying key risk factors. Unlike traditional methods, the framework remains valid under distribution shifts and combines uncertainty estimation with model interpretability. These advantages collectively lay a foundation for developing proactive traffic safety applications and formulating data-driven road safety policies.

PMID:40828994 | DOI:10.1080/15389588.2025.2538725