Nevin Manimala

J Magn Reson Imaging. 2025 Nov 4. doi: 10.1002/jmri.70162. Online ahead of print.

ABSTRACT

BACKGROUND: Access to prostate MRI remains limited due to resource constraints and the need for expert interpretation.

PURPOSE: To develop machine learning (ML) models that enable risk-based triage for prostate MRI (ProMT-ML) in the evaluation of prostate cancer.

STUDY TYPE: Retrospective and prospective.

POPULATION: A total of 11,879 retrospective MRI scans for suspected prostate cancer from a multi-hospital health system, divided into training (N = 9504) and test (N = 2375) sets. A total of 4551 records for prospective validation.

FIELD STRENGTH/SEQUENCE: 1.5T and 3T/Turbo-spin echo T2-weighted imaging (T2WI), diffusion-weighted imaging (DWI), and dynamic contrast-enhanced (DCE).

ASSESSMENT: Prostate Imaging Reporting and Data System (PI-RADS) scores were retrieved from MRI reports. The Boruta algorithm was used to select final input features from candidate features. Two models were developed using supervised ML to estimate the likelihood of an abnormal MRI, defined as PI-RADS ≥ 3: Model A (with prostate volume) and Model B (without prostate volume). Models were compared to PSA. Prostate biopsy pathology was assessed to evaluate potential clinical impact.

STATISTICAL TESTS: Area under the receiver operating characteristic curve (AUC) was the primary performance metric.

RESULTS: A total of 5580 (46.9%) subjects had a PI-RADS score ≥ 3. After feature selection, Model A included age, PSA, body mass index, and prostate volume, while Model B included age, PSA, body mass index, and systolic blood pressure. Both models A (AUC 0.711) and B (AUC 0.616) significantly outperformed PSA (AUC 0.593). Compared to PSA threshold > 4 ng/mL, Model A demonstrated significantly improved specificity (28.3% vs. 21.9%) and no significant difference in sensitivity (89.0% vs. 86.7%). Among false negatives (Model A: 8.0% (62/776); Model B: 16.8% (130/776)), most (Model A: 87%; Model B: 69%) had benign or clinically insignificant disease on biopsy. On prospective validation, both versions of ProMT-ML significantly outperformed PSA.

DATA CONCLUSION: ProMT-ML provides personalized risk estimates of abnormal prostate MRI and can support triage of this test.

TECHNICAL EFFICACY: Stage 4.

PMID:41186967 | DOI:10.1002/jmri.70162

JAMA Netw Open. 2025 Nov 3;8(11):e2541321. doi: 10.1001/jamanetworkopen.2025.41321.

NO ABSTRACT

PMID:41186952 | DOI:10.1001/jamanetworkopen.2025.41321

JAMA Netw Open. 2025 Nov 3;8(11):e2540730. doi: 10.1001/jamanetworkopen.2025.40730.

ABSTRACT

IMPORTANCE: The choice of first line hormonal therapy in metastatic hormone-sensitive prostate cancer (mHSPC) is often based on comorbidities or physician preference due to the lack of data comparing abiraterone and enzalutamide in clinical trials and in clinical practice settings, especially in African American patients.

OBJECTIVE: To compare clinical outcomes in patients with mHSPC treated with abiraterone acetate or enzalutamide.

DESIGN, SETTING, AND PARTICIPANTS: This cohort study included all patients with mHSPC diagnoses in the US Veterans Affairs Health Care system who initiated abiraterone or enzalutamide between July 2017 and April 2023. Data were analyzed from April 2024 to March 2025.

EXPOSURES: Receipt of abiraterone acetate or enzalutamide.

MAIN OUTCOMES AND MEASURES: Drug outcomes were established by estimating rates of tumor growth (g-rates) using prostate-specific antigen (PSA) values while receiving therapy and measuring overall survival (OS). Two different matching analyses were performed: inverse probability weighting (IPW) and 1:1 exact matching.

RESULTS: A total of 1258 patients (median [IQR] age, 73 [69-79] years; 314 [25.0%] African American, 857 [68.1%] White, and 87 [6.9%] with other or unknown race) who received abiraterone and 311 patients (median [IQR] age, 74 [69-79] years; 84 [27.0%] African American, 207 [66.6%] White, and 20 [6.4%] with other or unknown race) who received enzalutamide were included. In the unweighted analysis, the abiraterone cohort had median (IQR) g-rate of 0.000137/d (0.000094-0.001519) and the enzalutamide cohort, 0.000137/d (0.000098-0.001815); median (IQR) OS was 36.2 (32.8-38.8) months for abiraterone and 36.2 (34.1-40.5) months for enzalutamide, with a median (IQR) follow-up of 28.7 (15.6-45.6) and 30.8 (16.1-39.1) months, respectively. In IPW analysis, using abiraterone as reference, the weighted median OS was comparable between abiraterone and enzalutamide in the full cohort (36.2; 95% CI, 32.8-38.8 vs 35.5; 95 % CI, 32.9-40.4 months; hazard ratio [HR], 1.09; 95% CI, 0.92-1.30; P = .32), African American veterans (39.7; 95% CI, 34.3-46.6 vs 40.3; 95% CI, 34.3-not reached months; HR, 0.98; 95% CI, 0.72-1.34; P = .90) and those with cardiovascular disease (31.5; 95% CI, 28.1-35.5 vs 35.0; 95% CI, 30.7-38.9; HR, 1.12; 95% CI, 0.91-1.37; P = .30). In 1:1 matched analysis, both the abiraterone and enzalutamide groups had 279 patients with 63 (23%) who were African American; these patients had a median (IQR) follow-up of 27.3 (15.3-40.8) and 31.1 (16.8-39.9) months, respectively. The 1:1 matched cohort consisted of 158 patients (57%) in each group with an initial Gleason score of 8 or higher, and 224 patients (80%) in each group with a PSA value of 50 ng/mL or higher at treatment initiation. For the 1:1 matched cohort and its subgroups of African American patients, patients with Gleason scores of 8 or higher, and patients with a starting PSA level of 50 ng/mL or higher, no statistically significant difference in median g-rate and OS was observed.

CONCLUSIONS AND RELEVANCE: This cohort study found that abiraterone and enzalutamide had comparable outcomes in a first-line mHSPC setting, with similar g-rates and OS in both White and African American patients. There were no differences in survival or g-rate between treatment based on race, comorbidities, and prostate cancer features, including Gleason score, PSA, and volume of disease.

PMID:41186950 | DOI:10.1001/jamanetworkopen.2025.40730

JAMA Netw Open. 2025 Nov 3;8(11):e2541255. doi: 10.1001/jamanetworkopen.2025.41255.

ABSTRACT

IMPORTANCE: Advanced imaging to diagnose pulmonary embolism (PE) during pregnancy increases costs, ionizing radiation exposure, and the risk of overdiagnosis. D-dimer testing can exclude PE and compression ultrasonography can diagnose deep vein thrombosis (DVT), both reducing advanced imaging needs. How these 2 strategies are used in community PE diagnostics is unknown.

OBJECTIVE: To analyze the use and efficiencies of D-dimer and ultrasonography for the diagnosis of antenatal PE.

DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study was performed in 21 US community hospitals from October 1, 2021, to March 31, 2023. Participants included pregnant patients who underwent D-dimer testing, compression ultrasonography, or advanced imaging for suspected PE.

EXPOSURES: D-dimer testing or ultrasonography.

MAIN OUTCOMES AND MEASURES: The main outcome was avoidance of advanced imaging, measured by the number needed to test (NNT) to avoid 1 advanced imaging study using low to intermediate D-dimer values or a positive ultrasonography finding. Variables associated with D-dimer and ultrasonography were evaluated using quasi-Poisson regression reported as adjusted relative risks (ARRs).

RESULTS: A total of 720 outpatient encounters in 699 patients were included in the analysis (median age, 30.2 [IQR, 24.3-36.1] years). D-dimer testing was obtained in 524 patients (72.8%). Advanced imaging was not pursued in 149 of 155 patients (96.1%) with low (<0.5 mg/L) and 82 of 179 (45.8%) with intermediate (0.5 to <1.0 mg/L) D-dimer values, yielding an NNT to avoid 1 advanced imaging study of 2.3 (95% CI, 2.0-2.6). No 90-day venous thromboembolism or death occurred following rule-outs. D-dimer testing was less commonly used in third (vs first) trimester (ARR, 0.85; 95% CI, 0.75-0.97); with unilateral signs or symptoms of DVT (vs none) (ARR, 0.67; 95% CI, 0.54-0.82), and during labor and delivery unit (vs emergency department) evaluation (ARR, 0.27; 95% CI, 0.20-0.35). Compression ultrasonography was performed in 229 patients (31.8%), with DVT diagnosed in 3 (1.3%). Advanced imaging was not pursued in 2 of these patients, yielding an NNT to avoid 1 advanced imaging study of 115 (95% CI, 32-417). Ultrasonography use and results varied by DVT symptoms. Among 55 patients with DVT symptoms, 46 (83.6%) underwent ultrasonography, with positive findings in 3 (yield of 6.5%). Among 665 patients without symptoms, 183 (27.5%) underwent ultrasonography, with negative findings in all (yield of 0).

CONCLUSIONS AND RELEVANCE: In this cohort study, use of D-dimer testing was efficient and safe with opportunities for expansion across settings and patients. These findings suggest that ultrasonography efficiency was low but could be improved with symptom-driven use in antenatal PE diagnostics.

PMID:41186948 | DOI:10.1001/jamanetworkopen.2025.41255

JAMA Netw Open. 2025 Nov 3;8(11):e2541272. doi: 10.1001/jamanetworkopen.2025.41272.

ABSTRACT

IMPORTANCE: Outpatient follow-up after discharge has been associated with reduced 30-day readmissions. Since universal follow-up is not feasible, identifying for whom and when outpatient follow-up is most beneficial is essential for optimizing resources and reducing readmissions.

OBJECTIVE: To quantify the association between outpatient follow-up within 30, 14, and 7 days postdischarge and 30-day all-cause readmissions and assess differences in outcomes by disease, age, and baseline readmission risk.

DATA SOURCES: MEDLINE (via PubMed), Embase, and CINAHL were searched for studies published between January 1, 2000, and August 4, 2025, using terms related to outpatient follow-up and readmissions.

STUDY SELECTION: English-language studies assessing the association between outpatient follow-up within 30 days of hospital discharge and 30-day all-cause readmissions among adult inpatients were included.

DATA EXTRACTION AND SYNTHESIS: Following Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines, 2 reviewers independently screened titles and abstracts. Data were extracted by 1 author and verified by another, and quality assessment was done independently by 2 authors.

MAIN OUTCOMES AND MEASURES: The primary outcome was all-cause 30-day readmission. Secondary outcomes included all-cause 30-day emergency department (ED) discharge and mortality. Pooled effect sizes (relative risk ratios [RRRs]) were estimated by disease and age group using multilevel random-effects models.

RESULTS: Eighty-three studies were included in the review and 76 in the meta-analysis. Outpatient follow-up within 30 days vs no follow-up was associated with a reduction in risk of 30-day all-cause readmission (RRR, 0.68; 95% CI, 0.60-0.75), with less reduction (RRR, 0.78; 95% CI, 0.67-0.89) when restricted to studies with low to moderate risk of bias (ROB). Among patients with heart failure (HF) and acute myocardial infarction (AMI), the RRRs for 30-day follow-up in studies with low to moderate ROB were 0.65 (95% CI, 0.48-0.83) and 0.56 (95% CI, 0.32-0.80), respectively. Subgroup analysis using studies with low to moderate ROB showed benefits of 30-day follow-up only among patients aged 65 years or older with HF (RRR, 0.65; 95% CI, 0.48-0.83), AMI (RRR, 0.56; 95% CI, 0.32-0.80), and other diseases such as stroke and chronic obstructive pulmonary disease (RRR, 0.73; 95% CI, 0.59-0.87). Early follow-up vs no follow-up within 14 and 7 days was associated with a significant reduction in readmissions only among patients aged 65 years or older with HF (14 days: RRR, 0.63 [95% CI, 0.40-0.87]; 7 days: RRR, 0.68 [95% CI, 0.47-0.89]) and AMI (14 days: RRR, 0.57 [95% CI, 0.22-0.91]; 7 days: RRR, 0.63 [95% CI, 0.34-0.92]).

CONCLUSIONS AND RELEVANCE: In this systematic review and meta-analysis, outpatient follow-up within 30 days was associated with reduced 30-day readmissions, but the association varied by patient age and disease type, indicating a need for targeted rather than universal follow-up.

PMID:41186947 | DOI:10.1001/jamanetworkopen.2025.41272

JAMA Netw Open. 2025 Nov 3;8(11):e2541336. doi: 10.1001/jamanetworkopen.2025.41336.

ABSTRACT

IMPORTANCE: There are disparities in blood pressure (BP) levels by race in the US.

OBJECTIVE: To estimate the number of cardiovascular disease (CVD) events and deaths that could be prevented among non-Hispanic Black adults by achieving the same mean systolic BP (SBP) as non-Hispanic White adults 45 years or older.

DESIGN, SETTING, AND PARTICIPANTS: In this modeling study, the difference in mean SBP between non-Hispanic Black and non-Hispanic White US adults was calculated from the 2015-2020 cycles of the National Health and Nutrition Examination Survey (NHANES). The 10-year cumulative incidence of CVD, including stroke, coronary heart disease, and heart failure, and CVD mortality for non-Hispanic Black adults were calculated using data from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study. The relative risk reduction for CVD events and mortality with initiation and intensification of antihypertensive medication treatment was applied from the Blood Pressure Lowering Treatment Trialists Collaboration (BPLTTC), calibrated to reflect the SBP reduction for non-Hispanic Black adults to have the same SBP as non-Hispanic White adults. Data were analyzed from June 22, 2022, to August 13, 2025.

EXPOSURE: Systolic blood pressure.

MAIN OUTCOMES AND MEASURES: Number of CVD events and deaths. Using data from NHANES, REGARDS, and BPLTCC, the cumulative incidence of CVD events and deaths expected over the next 10 years with current SBP levels and with SBP equity was estimated.

RESULTS: Among 82.3 million US adults included in the study, 37.2 million (45.3%) were men, 45.0 million (54.7%) were women, 10.1 million (12.2%) were non-Hispanic Black, and 72.2 million (87.8%) were non-Hispanic White. The mean (SD) age was 60.8 (0.3) years. The mean SBP was 130.7 (95% CI, 129.0-132.5) mm Hg among non-Hispanic Black adults and 124.2 (95% CI, 123.1-125.3) mm Hg among non-Hispanic White adults for those not taking antihypertensive medication (difference, 6.5 [95% CI, 4.5-8.5] mm Hg), and 137.8 (95% CI, 135.8-139.8) mm Hg among non-Hispanic Black adults and 131.2 (95% CI, 129.7-132.7) mm Hg among non-Hispanic White adults for those taking antihypertensive medication (difference, 6.5 [95% CI, 4.0-9.1] mm Hg). Achieving equity in SBP between non-Hispanic Black and White adults was projected to reduce the number of CVD events during 10 years by 50 434 (95% CI, 33 985-71 137) among non-Hispanic Black US adults not taking antihypertensive medication and 122 881 (95% CI, 83 220-176 826) among non-Hispanic Black adults taking antihypertensive medication. Achieving equity in SBP between non-Hispanic Black and White adults was projected to reduce the number of CVD deaths during 10 years by 21 703 (95% CI, 7313-40 278) among non-Hispanic Black US adults not taking antihypertensive medication and 55 055 (95% CI, 19 823-99 693) among non-Hispanic Black adults taking antihypertensive medication. The largest proportion of CVD events and deaths prevented were among those aged 45 to 64 years. For example, more than half of CVD events prevented among non-Hispanic Black adults not taking antihypertensive medication (55%) were in that age group.

CONCLUSIONS AND RELEVANCE: The findings of this modeling study suggest that achieving SBP equity between non-Hispanic Black and White adults could substantially reduce the number of CVD events and deaths experienced by non-Hispanic Black US adults. Initiatives to maintain normal BP and achieve BP control for individuals with hypertension could have a substantial impact on health equity in the US.

PMID:41186946 | DOI:10.1001/jamanetworkopen.2025.41336

JAMA Netw Open. 2025 Nov 3;8(11):e2541401. doi: 10.1001/jamanetworkopen.2025.41401.

ABSTRACT

IMPORTANCE: Advance care planning (ACP) engagement is poorly understood among people with serious illness.

OBJECTIVE: Determine whether diagnosis of and worries about serious illness are associated with ACP engagement.

DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study was based on a nationally representative survey administered April to May 2021 online or by telephone. Eligible participants were adults and English or Spanish language. Data were analyzed May 2023 to February 2025).

EXPOSURE: Having a serious illness.

MAIN OUTCOMES AND MEASURES: Three domains of ACP engagement: discussion with people close to participants, discussion with clinicians, and documentation in writing. Barriers to ACP documentation and worries about serious illness were also assessed. Survey responses were weighted to reflect the US Census population. χ2 tests and multivariable logistic regression models were adjusted for covariables to assess associations between serious illness and each ACP outcome.

RESULTS: Among 1854 participants (468 [weighted percentage, 25.2%] aged 65 years or older; 955 women [weighted percentage, 51.9%]; 193 Black [weighted percentage, 12.0%], 288 Hispanic [weighted percentage, 16.7%], 1218 White [weighted percentage, 61.2%]), 367 (weighted percentage, 20%) had serious illness. Overall, 1254 (weighted percentage, 65.9%) had engaged in ACP (283 of 367 [weighted percentage, 76.5%] serious illness vs 971 of 1487 [weighted percentage, 62.6%] without serious illness; P < .001); 1071 (weighted percentage, 55.3%) discussed ACP with people close to them, 462 (weighted percentage, 22.5%) discussed with clinicians, and 650 (weighted percentage, 32.8%) documented a surrogate. People with serious illness had higher odds than those without having discussed choices for surrogates and medical wishes with people close to them (aOR, 1.57 [95% CI, 1.19-2.07] and 1.66 [95% CI, 1.26-2.19]) and with clinicians (aOR, 2.16 [95% CI, 1.63-2.88] and 2.22 [95% CI, 1.67-2.94]). Serious illness status was not associated with ACP documentation. The most common barriers to documentation were not having thought about it (489 of 1171 [weighted percentage, 43.1%]) and assuming surrogates would know what they want (369 of 1171 [weighted percentage, 32.2%]). Participants who were worried (vs not worried) about being able to afford care, surrogates making the best or right decisions, having access to the best treatments, or having high stress or symptoms had significantly higher rates of ACP engagement.

CONCLUSIONS AND RELEVANCE: In this survey study of adults in the US, we found that ACP discussions with someone close to them were high, yet discussions with clinicians and documentation were low, even among people with serious illness. Our findings offer insights into how people’s worries about serious illness care may affect their engagement in ACP, and how to leverage these insights to tailor patient-facing messaging about ACP.

PMID:41186945 | DOI:10.1001/jamanetworkopen.2025.41401

J Cardiovasc Surg (Torino). 2025 Nov 4. doi: 10.23736/S0021-9509.25.13370-3. Online ahead of print.

ABSTRACT

BACKGROUND: The aim of this paper was to compare the patient characteristics, procedural details, 30-day postoperative outcomes of carotid artery stenting (CAS) performed through radial access versus femoral access.

METHODS: This is a single-center, retrospective, non-randomized study conducted on 613 consecutive patients who underwent elective CAS between January 2015 and January 2025. Patients were divided into two groups based on access route: radial (N.=167) and femoral (N.=446). The following were considered as the primary endpoints: 1) the occurrence of one of TIA/stroke/death; and 2) the overall perioperative complications rate. Secondary endpoints included access-site complications, procedure duration, and single complication rate.

RESULTS: No significant differences were observed between the two groups in pre/intraoperative variables, except for the rate of symptomatic carotid stenosis (radial 22% vs. femoral 15%, P=0.030) and the use of dual-layer stents (radial 87% vs. femoral 75%, P<0.001). The TIA/Stroke/death rate (radial 1.8% vs. femoral 4.4%, P=0.119), overall perioperative complication rate (radial 5.4% vs. femoral 10%, P=0.057), and access-site complications (radial 0.6% vs. femoral 2%, P=0.217) were comparable between groups. However, the mean procedure time was significantly shorter in the radial group (36±15 minutes vs. 42±18 minutes, P<0.001).

CONCLUSIONS: Percutaneous radial access in CAS procedures was more frequently performed in symptomatic patients and with the use of newer low-profile dual-layer micromesh platforms. Radial access was associated with shorter procedural times and a trend toward lower perioperative complication rates, though the latter did not reach statistical significance.

PMID:41186916 | DOI:10.23736/S0021-9509.25.13370-3

Dig Dis Sci. 2025 Nov 4. doi: 10.1007/s10620-025-09517-7. Online ahead of print.

ABSTRACT

BACKGROUND: Caustic ingestion remains a significant public health concern, particularly in low- and middle-income countries, and often results in long-term complications such as esophageal strictures. Esophagogastroduodenoscopy (EGD) is widely used for grading mucosal injury (Zargar classification) but cannot assess wall depth. Endoscopic ultrasound (EUS) allows visualization of transmural involvement, yet its prognostic role in caustic injuries is underexplored.

METHODS: This prospective cohort study included 63 adults with confirmed caustic ingestion who underwent both EGD and EUS within 24 h. Zargar grades and EUS findings were recorded, and patients were followed for 12 weeks to assess stricture formation and clinical outcomes. Statistical comparisons were made between those who developed strictures and those who did not.

RESULTS: Median age was 25 years (interquartile range [IQR] 20-40), and 75% were female. Acid ingestion predominated (60%), and most cases (89%) were intentional. Strictures developed in 41% of patients, most frequently in the esophagus. Male sex was significantly associated with stricture formation (p = 0.015). All patients with Zargar grade IIIA/IIIB or muscularis/serosal involvement on EUS developed strictures, while none with Zargar I or mucosal-only involvement did. Dysphagia was the most common post-discharge symptom, reported by 40% at 12 weeks. No EUS-related complications occurred.

CONCLUSION: EUS appears promising in providing complementary prognostic information to EGD and may improve stricture risk stratification, particularly in intermediate- and high-grade injuries. Incorporating EUS into early evaluation could guide closer monitoring and intervention. Larger multicenter studies with longer follow-up are warranted.

PMID:41186906 | DOI:10.1007/s10620-025-09517-7

Eur Arch Paediatr Dent. 2025 Nov 4. doi: 10.1007/s40368-025-01128-0. Online ahead of print.

ABSTRACT

PURPOSE: The preformed metal crown (PMC) is an extremely durable restoration for cavitated carious primary molars. Clinically, the PMC is delivered either by the conventional technique (CT) or the more conservative Hall technique (HT). The present study aimed to compare procedural time, child pain perception and behaviour, and parent acceptability, when the CT or HT were used to restore carious primary molars with PMCs.

METHODS: This was a primary care-based, two-arm parallel-group, randomised controlled trial with 80 participants randomly assigned into the CT and HT groups. To ensure standardisation, potential participants were screened and treated by a single paediatric dentist. Outcome measures evaluated included the procedural time taken; child’s pain perception (Wong-Baker FACES Pain Scale); child behaviour (Frankl scale); and parental perceptions and acceptability (5-point Likert scales).

RESULTS: Procedural time required for the CT and HT treatment groups was 17.4 ± 2.9 and 7.1 ± 2.8 min, respectively (P < 0.001). Child self-reported pain intensity perception was statistically significantly higher in the CT group (Χ² = 12.27; P = 0.03). Dentist-evaluated child behaviour was comparable for both treatment groups with 65% of the CT group children and 85% of HT group children rated as ‘Positive’ or Definitively positive’. Parental perception of child’s comfort during the treatment procedure showed no statistically significant difference between children who received the CT versus the HT (Χ² = 5.97; P = 0.20). However, parents of children who underwent the HT expressed statistically significantly better responses with regard to procedural ease (Χ² = 21.74; P < 0.001), treatment duration (Χ² = 21.58; P < 0.001), satisfaction with the treatment procedure (Χ² = 22.04; P < 0.001), and desire to choose the same treatment procedure again (Χ² = 24.47; P < 0.001).

CONCLUSIONS: Compared to the CT, the HT of delivering PMCs to restore carious primary molars required shorter procedural time, elicited lower child pain perception, and better parent acceptability.

PMID:41186901 | DOI:10.1007/s40368-025-01128-0