Tag: nevin manimala

JAMA Netw Open. 2026 Apr 1;9(4):e265177. doi: 10.1001/jamanetworkopen.2026.5177.

ABSTRACT

IMPORTANCE: Guidelines recommend tailored (ie, individualized) exercise strategies for cancer survivors. However, there are limited data on the effects of these strategies on long-term mortality outcomes among breast cancer survivors.

OBJECTIVE: To estimate the effect of tailored exercise strategies on mortality for breast cancer survivors.

DESIGN, SETTING, AND PARTICIPANTS: In this cohort study, a target trial protocol was first specified to approximately mirror the Colon Health and Lifelong Exercise Change (CHALLENGE) trial among breast cancer survivors. Observational data from the Pathways Study were used to emulate this first target trial. These results were then extended by emulating a second target trial of more pragmatic, tailored exercise strategies applied to a broader population of breast cancer survivors. Women enrolled in the Kaiser Permanente Northern California health plan were recruited from January 2006 to December 2013, and were followed up through December 2021. Analyses were performed between September 2024 and September 2025.

EXPOSURES: Tailored exercise strategies adaptively modified based on evolving characteristics.

MAIN OUTCOMES AND MEASURES: All-cause and breast cancer-specific mortality.

RESULTS: In the first target trial, there were 959 eligible women (mean [SD] age, 58.3 [12.5] years) and 183 deaths. Compared with a strategy similar to the health education intervention of the CHALLENGE trial, an aerobic exercise strategy was associated with an 8.0 (95% CI, 3.4-13.3)-percentage point lower 8-year all-cause mortality risk, which was compatible with the CHALLENGE trial (7.1 [95% CI, 1.8-12.3]-percentage point lower risk). In the second target trial, there were 2107 eligible women (mean [SD] age, 60.1 [12.1] years) and 321 deaths. Estimated 10-year all-cause mortality ranged from 18.1% to 21.2%. Breast cancer-specific mortality ranged from 7.6% to 10.0%. Compared with no intervention, engaging in a tailored strategy requiring an increase of 60 minutes of vigorous or 120 minutes of moderate aerobic exercise per week was associated with a 3.1 (95% CI, 2.0-4.6)-percentage point lower 10-year all-cause mortality risk and a 2.4 (95% CI, 1.2-3.5)-percentage point lower 10-year breast cancer-specific mortality risk.

CONCLUSIONS AND RELEVANCE: In this cohort study using a target trial emulation design, tailored exercise strategies were associated with reductions in 10-year mortality among breast cancer survivors. A randomized trial is warranted to confirm these findings.

PMID:41973424 | DOI:10.1001/jamanetworkopen.2026.5177

JAMA Netw Open. 2026 Apr 1;9(4):e266100. doi: 10.1001/jamanetworkopen.2026.6100.

ABSTRACT

IMPORTANCE: Familial hypercholesterolemia is a common genetic disorder associated with premature cardiovascular disease. Genetic cascade screening is recommended but remains underused due to privacy laws that prevent clinicians from directly contacting at-risk relatives.

OBJECTIVE: To examine whether implementing a web-based communication platform in a patient-mediated genetic cascade screening program for familial hypercholesterolemia increases uptake compared with usual care.

DESIGN, SETTING, AND PARTICIPANTS: This open-label, multicenter, implementation randomized clinical trial (CATCH) was conducted between November 1, 2020, and October 31, 2023, at 7 cardiovascular prevention or lipid clinics across Switzerland, representing French-, German-, and Italian-speaking regions. Adults aged 16 years or older with genetically confirmed familial hypercholesterolemia and at least 1 eligible first-degree relative living in Switzerland participated. A total of 87 index patients with 359 eligible first-degree relatives were randomized by family cluster (1:1) to the intervention or usual care arm.

INTERVENTION: A secure web-based platform allowing participants to send preprepared electronic messages (email or text) to their relatives, linking them directly to participating centers for genetic testing.

MAIN OUTCOMES AND MEASURES: The primary outcome was cascade screening uptake, defined as the proportion of eligible first-degree relatives undergoing genetic testing within 6 months. The secondary outcome was new cases identified.

RESULTS: Among 221 adults screened across multiple families, 87 (39.4%) had genetically confirmed familia hypercholesterolemia (median [IQR] age, 49.2 [16.4-83.7] years; 46 [52.9%] female; median [IQR] highest low-density lipoprotein cholesterol, 289.58 [139.00-498.07] mg/dL); 43 were randomized to the usual care arm, and 44 were randomized to the intervention arm. Among the 359 eligible relatives (median family size, 4), 99 (27.6%) underwent genetic testing. Uptake was higher in the intervention arm (30.4%; 95% CI, 22.0%-40.4%) than in usual care arm (16.7%; 95% CI, 10.1%-26.3%), yielding an odds ratio of 2.18 (95% CI, 1.06-4.51; P = .03). New case identification was also greater (17.0% vs 8.1%; odds ratio, 2.32; 95% CI, 1.07-5.05; P = .03). Newly identified patients were often untreated or had modifiable risk factors.

CONCLUSIONS AND RELEVANCE: In this randomized clinical trial of patient-mediated genetic cascade screening supported by a web-based platform, participation in genetic testing and detection of familial hypercholesterolemia was increased compared with usual care. These results suggest that the use of digital communication tools enhanced the reach and effectiveness of genetic screening programs within privacy-regulated health systems.

TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04419090.

PMID:41973423 | DOI:10.1001/jamanetworkopen.2026.6100

JAMA Netw Open. 2026 Apr 1;9(4):e266458. doi: 10.1001/jamanetworkopen.2026.6458.

ABSTRACT

IMPORTANCE: Patients with sickle cell disease (SCD) may experience clinician biases due to intersecting stigmatizing factors because most patients with SCD racially identify as Black, have pain as the most common presenting symptom, and are often treated with opioids.

OBJECTIVE: To examine intersecting stigmatizing identities of patients with SCD-identifying as Black, presenting with pain, and being treated with opioids-and compare differences in negative descriptors in the electronic health record relative to SCD.

DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional, single-center study of outpatient, emergency department, and inpatient encounters examined clinician notes from January 1, 2019, to October 1, 2020. Clinician notes were included for patients who racially identified as Black or had diagnoses of SCD, chronic pain, or opioid use disorder (OUD). Notes were also included for a counterfactual group of patients who were not Black and did not have SCD, chronic pain, or OUD. Data were analyzed from November 2024 to February 2026.

EXPOSURE: Patients with SCD were compared with 4 groups, all without SCD: (1) Black patients, (2) patients with chronic pain, (3) patients with OUD, and (4) the counterfactual group.

MAIN OUTCOMES AND MEASURES: Using natural language processing and a machine learning model, clinician notes were contextually coded for the application of 7 negative descriptors: aggressive, agitated, angry, nonadherent, noncompliant, noncooperative, and refuse.

RESULTS: A total of 39 871 clinician notes across 18 326 patients were analyzed (mean [SD] age, 47 [23] years); 2183 patients were pediatric (12%), 10 243 were female (56%), 11 137 were Black (63%), 5907 were married (32%), and 5884 had Medicaid (32%). Negative descriptors were present in 220 of 1443 notes (15%) among patients with SCD and 124 of 643 notes (19%) among those with all 4 stigmatizing identities. There were higher odds of a negative descriptor in notes about patients with SCD compared with Black patients without SCD (aOR, 2.46; 95% CI, 1.62-3.73), patients with chronic pain without SCD (aOR, 1.96; 95% CI, 1.18-3.27), and patients in the counterfactual group (aOR, 14.26; 95% CI, 5.92-34.36), but there was no difference compared with patients with OUD without SCD (aOR, 0.76; 95% CI, 0.42-1.38).

CONCLUSIONS AND RELEVANCE: In this cross-sectional study of 18 326 patients, those with SCD had more negative descriptors than Black patients without SCD or those with chronic pain but at a similar level as those with OUD.

PMID:41973422 | DOI:10.1001/jamanetworkopen.2026.6458

JAMA Netw Open. 2026 Apr 1;9(4):e266571. doi: 10.1001/jamanetworkopen.2026.6571.

ABSTRACT

IMPORTANCE: Psychiatric disorders are a major global public health concern, highlighting the urgent need for policies to mitigate their impact, especially for at-risk populations.

OBJECTIVE: To investigate the association of the Brazilian conditional cash transfer program (Bolsa Familia Program [BFP]) with psychiatric disorder hospitalizations and availability of community mental health service.

DESIGN, SETTING, AND PARTICIPANTS: This cohort study was conducted during an 8-year period using linked social and health data from the 100 Million Brazilian Cohort. The participants were all individuals who were registered at CadÚnico between January 1, 2008, and December 31, 2015. Statistical analyses were conducted between August 12, 2025, and January 31, 2026.

EXPOSURE: Participation in the BFP.

MAIN OUTCOMES AND MEASURES: All psychiatric disorder hospitalizations registered on the Hospital Information System according to International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) as psychiatric disorders, except for substance use disorders.

RESULTS: A total of 38 572 143 individuals (mean [SD] age, 21.66 [22.06] years; 20 661 009 [54%] female and 17 911 134 [44%] male; 188 033 [0.49%] Asian, 2 238 344 [5.80%] Black, 280 859 [0.73%] Indigenous, 22 123 435 [57.36%] Pardo [includes individuals with Black or mixed ancestry, including European, African, and Indigenous heritage], and 12 749 758 [33.05%] White) were included in the analysis. A total of 56 646 individuals (0.1%) had a psychiatric disorder hospitalization during the study period. Individuals who received a cash transfer from the BFP had a 23% lower risk of psychiatric disorders hospitalization (hazard ratio [HR], 0.77; 95% CI, 0.76-0.79). The association was stronger among Pardo (HR, 0.72; 95% CI, 0.69-0.74) and Black (HR, 0.78; 95% CI, 0.72-0.85) individuals who lived in the poorest municipalities (HR, 0.67; 95% CI, 0.63-0.71) regardless community mental health care.

CONCLUSIONS AND RELEVANCE: In this cohort study of the 100 Million Brazilian Cohort, a national cash transfer program was associated with lower risk of psychiatric hospitalizations, especially among at-risk populations who experience health inequalities.

PMID:41973421 | DOI:10.1001/jamanetworkopen.2026.6571

JAMA Netw Open. 2026 Apr 1;9(4):e266771. doi: 10.1001/jamanetworkopen.2026.6771.

ABSTRACT

IMPORTANCE: Syphilis, which is caused by Treponema pallidum, has historically been associated with cardiovascular complications. Despite a resurgence of syphilis incidence in the US, large-scale studies evaluating its independent cardiovascular impact are lacking.

OBJECTIVE: To determine whether syphilis infection is independently associated with increased risk of adverse cardiovascular outcomes in a US health system population.

DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study with a 15-year follow-up (January 1, 2011, to July 1, 2025) was performed within a tertiary health care system in New Orleans, Louisiana. Participants included adults with syphilis identified using codes from the International and Statistical Classification of Diseases, Tenth Revision (ICD-10) and controls without syphilis who were matched based on demographic characteristics and comorbidities. Patients with preexisting cardiovascular disease were excluded. Data were analyzed from January 1, 2011, to July 1, 2025.

EXPOSURES: Diagnosis of syphilis (primary, secondary, tertiary, or unspecified stage) documented by ICD-10 codes.

MAIN OUTCOMES AND MEASURES: Incident cardiovascular events included myocardial infarction, heart failure, aortic regurgitation, atrial fibrillation, aortic aneurysm or dissection, ischemic stroke, hemorrhagic stroke, peripheral artery disease, venous thromboembolism, and death. Outcomes were assessed using Kaplan-Meier survival curves and were adjusted for body mass index.

RESULTS: A total of 8814 participants were included in the analysis (4753 [53.9%] female; mean [SD] age, 50.0 [17.0] years). The syphilis group (n = 1469) and control group (n = 7345) were similar in terms of their demographic characteristics (mean [SD] age, 50.1 [17.0] vs 50.0 [17.6] years [P = .78]; 795 [54.1%] vs 3958 [53.9%] female [P = .84]) and comorbidities. In adjusted analyses, syphilis was associated with an increased risk of aortic aneurysm or dissection (hazard ratio [HR], 2.08; 95% CI, 1.47-2.94; P = .001), ischemic stroke (HR, 1.53; 95% CI, 1.27-1.84; P < .001), hemorrhagic stroke (HR, 1.92; 95% CI, 1.23-2.99; P = .004), peripheral artery disease (HR, 1.28; 95% CI, 1.01-1.62; P = .04), death (HR, 5.80; 95% CI, 3.81-8.82; P < .001), and myocardial infarction (HR, 1.33; 95% CI, 1.06-1.67; P = .01). No associations were found for heart failure (HR, 0.98; 95% CI, 0.83-1.17), atrial fibrillation (HR, 0.85; 95% CI, 0.67-1.08), aortic regurgitation (HR, 1.58; 95% CI, 0.87-2.87), or venous thromboembolism (HR, 1.47; 95% CI, 0.76-2.94).

CONCLUSIONS AND RELEVANCE: In this retrospective cohort study of adults with syphilis, infection was independently associated with higher risk of several major cardiovascular outcomes. These findings underscore the importance of early detection and treatment of syphilis and suggest a role for incorporating cardiovascular risk assessment into comprehensive syphilis management strategies.

PMID:41973418 | DOI:10.1001/jamanetworkopen.2026.6771

JAMA. 2026 Apr 13. doi: 10.1001/jama.2026.3446. Online ahead of print.

ABSTRACT

IMPORTANCE: Transcatheter tricuspid valve replacement (TTVR) demonstrated superior outcomes over medical therapy in patients with severe tricuspid regurgitation (TR) in the Edwards EVOQUE Transcatheter Tricuspid Valve Replacement: Pivotal Clinical Investigation of Safety and Clinical Efficacy Using a Novel Device II (TRISCEND II) randomized clinical trial, and received regulatory approval in the US in 2024. Contemporary real-world data on its effectiveness and safety remain limited.

OBJECTIVE: To evaluate 30-day clinical, echocardiographic, and health status outcomes of TTVR in real-world use.

DESIGN, SETTING, AND POPULATION: Retrospective cohort study of all consecutive patients who underwent TTVR in the US from February 2024 through March 2025 in the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry. Patients had symptomatic, severe TR despite optimal medical therapy and TTVR was deemed appropriate by a heart team. Statistical analysis was conducted from September 2025 to February 2026.

EXPOSURE: Device-enabled TTVR.

MAIN OUTCOMES AND MEASURES: Thirty-day event rates (all-cause death, stroke, bleeding, new cardiac implantable electronic device [CIED] implantation, heart failure hospitalizations), TR reduction, and changes in health status (New York Heart Association [NYHA] functional class and Kansas City Cardiomyopathy Questionnaire Overall Summary [KCCQ-OS] score) are reported. Subgroup analyses examined the impact of baseline CIED status on outcomes.

RESULTS: Among 1034 attempted procedures at 82 centers (mean [SD] age, 77.1 [10.6] years; 69.1% female; 73.2% NYHA functional class III/IV), a valve was successfully implanted in 1017 patients (98.4%). Mild or less TR was achieved in 98.4% of patients post procedure and in 97.7% at 30 days. At 30 days, all-cause mortality was 3.1%; stroke, 0.2%; bleeding, 7.9%; new CIED, 15.9% in CIED-naive patients; and heart failure hospitalization, 3.1%. There were significant improvements in NYHA functional class (class I/II, 82.7%; P < .001) and mean KCCQ-OS score (22.4 points; P < .001) from baseline to 30 days. There were no significant differences in 30-day mortality (P = .47), heart failure hospitalization (P > .99), and functional outcomes (P = .55) when patients were stratified by baseline CIED status.

CONCLUSIONS AND RELEVANCE: Early US real-world experience with TTVR confirms safety and effectiveness in patients with severe TR. Thirty-day outcomes are consistent with the TRISCEND II pivotal trial, demonstrating acceptable safety, near-complete TR elimination, and significant health status improvements in an older, comorbid population. Rates of new CIED implantation and bleeding were lower than randomized clinical trial experience.

PMID:41973411 | DOI:10.1001/jama.2026.3446

Acad Emerg Med. 2026 Apr;33(4):e70287. doi: 10.1111/acem.70287.

ABSTRACT

OBJECTIVES: Patients and experts agree that potentially inappropriate medications should be reconsidered after adverse drug events (ADEs), yet emergency providers are often hesitant to discuss deprescribing in deference to outpatient prescribers. We sought to explore patient communication preferences for deprescribing in the emergency department (ED) after an ADE.

METHODS: We conducted a cross-sectional survey study of older adults aged 65 years and older presenting to a southeastern, academic ED from June 2024 to October 2024. While awaiting results, eligible participants completed a best-worst scaling survey comparing seven potential ED communication strategies for prompting deprescription of daily aspirin. The primary analysis tested whether an ED-initiated “therapeutic pause” (“Considering your bleeding, I would like you to hold your aspirin until you can discuss with your primary care provider”) was preferred by > 50% of participants over a generic discharge referral to a primary care provider through a one-sided binomial test. Secondary analyses used conditional logistic regression to evaluate relative preference across all seven deprescribing phrases.

RESULTS: In total, 102 patients completed the survey with a mean (SD) age of 75 years old (std dev 7). Among all respondents, 62% (95% CI, 52%-71%) preferred an ED-initiated ‘therapeutic pause’ of aspirin with primary care follow-up to the generic PCP deferral approach (p = 0.01). The least preferred statement was a strict deprescribing recommendation (“I do not think you need aspirin anymore”), which was selected as the least-favored communication approach in 65% of choice tasks. In conditional logistic regression, the therapeutic pause had greater odds of being selected as most preferred compared to the least preferred phrase (OR 9.3; 95% CI, 6.3-13.8).

CONCLUSION: Our study suggests that ED physicians may take a proactive approach in addressing potential deprescribing in caring for patients with ADEs, such as initiating a therapeutic pause of aspirin after an episode of bleeding.

PMID:41973408 | DOI:10.1111/acem.70287

Acad Emerg Med. 2026 Apr;33(4):e70288. doi: 10.1111/acem.70288.

ABSTRACT

BACKGROUND: In select situations, patients experiencing out-of-hospital cardiac arrest (OHCA) may be candidates for extracorporeal cardiopulmonary resuscitation (ECPR). Eligibility criteria for ECPR typically include a maximum time (usually 30 min) from arrest to arrival at an ECPR-capable center, which may exclude populations based on geographic factors.

METHODS: Using geospatial modeling, we calculated drive times to ECPR-capable hospitals in Boston utilizing census block group centroid coordinates as proxy sites for OHCA locations. We used a fixed dispatch-to-scene arrival time of 7.4 min, extrapolated from Boston EMS median transport time data. We set conditions at the 50th (24 min), 25th (18 min), and 10th (13 min) percentiles for EMS on-scene time and, for each condition, determined access to ECPR with an arrest to arrival criterion of less than 30 min. We analyzed the effect of high- versus low-traffic conditions and then derived the arrest to arrival time necessary to achieve access for 90% of the city.

RESULTS: The entire City of Boston was excluded from ECPR with median times and current eligibility criteria. Decreasing time-on-scene to the 25th percentile led to increased access: 16% of block groups with low traffic and 6% of block groups with high traffic. At the 10th percentile for time-on-scene, 55% of block groups had access with low traffic and 28% had access with high traffic. To achieve access for 90% of the city under high-traffic conditions at the 50th percentile for time-on-scene, the criterion for arrest to arrival would need to be extended to 55.8 min.

CONCLUSIONS: The current arrest to arrival criterion for ECPR excludes the entire City of Boston using median transportation and on-scene times. Increasing access to ECPR should include efforts to decrease prehospital duration, such as minimizing time-on-scene for potential OHCA cases. Future study should examine potential levers to improve access, such as novel prehospital ECPR delivery models, air-based transport, and liberalized arrest to arrival criteria.

PMID:41973406 | DOI:10.1111/acem.70288

Can J Public Health. 2026 Apr 13. doi: 10.17269/s41997-026-01198-7. Online ahead of print.

ABSTRACT

OBJECTIVES: In Canada, most tuberculosis diagnoses occur among people previously residing in tuberculosis-endemic regions, due to progression of infection acquired prior to arrival. National guidelines recommend screening people with medical risk factors, known exposure, or specific demographic characteristics. The best strategy to reach this latter group remains uncertain, though primary care may serve as a promising entry point. We aimed to (1) describe primary care use among new permanent residents to British Columbia and (2) estimate the proportion of tuberculosis potentially preventable under a hypothetical primary care-based demographic screening policy.

METHODS: We conducted a retrospective, population-based study of permanent residents to British Columbia (2000-2020) using linked administrative data. We measured time to first primary care visit and assessed tuberculosis preventability among those eligible for demographic-based screening (≤ 65 years from countries with tuberculosis incidence ≥ 200 per 100,000 within 5 years of arrival). Tuberculosis was considered potentially preventable if diagnosed ≥ 12 months after first primary care visit.

RESULTS: Among 845,821 new permanent residents, 708,813 (83.8%) accessed primary care (median months, 15) and 286,337 (33.9%) met the demographic screening criteria. During follow-up, 1315 (0.2%) were diagnosed with tuberculosis (median months to diagnosis, 48.8). Of these, 859 (65.3%) met demographic screening criteria and a primary care screening model could have potentially prevented 420 (48.9%) of these events, equivalent to one-third of all diagnoses in the cohort.

CONCLUSION: Timely, demographic-based screening in primary care could have potentially prevented one-third of tuberculosis diagnoses. Strengthening engagement and reducing access barriers will be essential to support tuberculosis elimination.

PMID:41973386 | DOI:10.17269/s41997-026-01198-7

Discov Ment Health. 2026 Apr 13. doi: 10.1007/s44192-026-00407-6. Online ahead of print.

ABSTRACT

BACKGROUND: Insufficient sleep is a common public health issue among students, and it is necessary to investigate this phenomenon and its consequences. Therefore, the present study aimed to examine the psychological consequences (i.e., somatization, depression, anxiety, and hostility) of insufficient sleep in medical students.

METHODS: The sample in this cross-sectional study consisted of 448 college students (with a mean age of 23.47 years; 56.7% female) from Kermanshah University of Medical Sciences at Iran. Symptom Checklist-90-Revised Form (SCL-90-R) and several self-report questionnaires (physical activity, bedtime, sleep duration, and daily nap) were used to collect data, and the results were analyzed using ANOVA and ANCOVA.

RESULTS: The results showed statistically significant differences in the mean scores of anxiety (F = 10.84, η² = 0.070), depression (F = 7.52, η² = 0.050), somatization (F = 13.07, η² = 0.082), and hostility (F = 5.28, η² = 0.035) among groups based on sleep duration. These differences remained significant even after controlling for the effects of physical activity, bedtime and daytime napping (all p < 0.01).

CONCLUSION: According to the results, insufficient sleep and short sleep duration are significantly associated with elevated anxiety, depression, somatization, and hostility. A key limitation is the reliance on a single self-report item for assessing sleep duration, which is subject to recall bias. Future longitudinal studies with objective sleep measures be conducted to explore the causal links between sleep duration and mental health.

PMID:41973370 | DOI:10.1007/s44192-026-00407-6