Medicaid provides comprehensive dental coverage to more than 37 million children in the US and plays a central role in reducing barriers to care and improving oral health outcomes. Under the 2025 One Big Beautiful Bill Act (OBBBA), many of these children may be at risk of losing their Medicaid coverage. To estimate changes in oral health outcomes and health care costs associated with projected Medicaid coverage loss among US children. A stochastic decision-analytic microsimulation model was developed to project changes in oral health and economic outcomes associated with Medicaid coverage loss among US children aged 0 to 18 years over a 10-year horizon (2025-2034). Simulated population characteristics were informed by the nationally representative National Health and Nutrition Examination Survey (NHANES) 2013-2018. Sensitivity analyses evaluated uncertainty in policy magnitude and structural assumptions. All analyses were performed from July 25 to March 2, 2025. Projected annual Medicaid disenrollment of 480 000 children under the 2025 OBBBA from 2025 through 2034. Incremental incident caries events and emergency department visits for nontraumatic dental-related conditions, quality-adjusted life-years (QALYs), and health care costs. The simulated cohort was based on 11 696 NHANES participants aged younger than 19 years (mean [SD] age, 9.2 [0.1] years; 5778 [weighted percentage, 49.2%] females). Over 10 years, projected coverage loss was associated with 95 799 (95% uncertainty interval [UI], 15 107-171 514) additional incident caries events, 27 084 (95% UI, -41 015 to -12 458) QALYs lost, and $86.5 million (95% UI, $47.1-$125.1 million) in additional health care costs in the base-case scenario. Across alternative policy impact scenarios, incremental caries events ranged from 54 051 (95% UI, -5354 to 111 084) to 161 231 (95% UI, 58 630-261 271), and incremental costs ranged from $47.9 million (95% UI, $17.1-$77.6 million) to $145.8 million (95% UI, $92.5-$193.4 million). In this decision-analytic microsimulation modeling study, projected pediatric Medicaid coverage loss was associated with worsening oral health outcomes and increased health care costs. The magnitude of impact varied with the scale of coverage loss but remained adverse across alternative policy scenarios.

As of September 2024, federal legislation mandates that patients be informed of their breast density, a modest breast cancer risk factor and known cancer-masking agent. This binary metric, dense vs nondense, applies to 40% to 50% of women and is subjectively assessed with interreader variability, limiting its utility for guiding supplemental imaging. To compare the performance of a deep learning (DL) breast cancer risk model vs radiologist-assessed breast density in estimating future breast cancer and false-negative (FN) screening results. This retrospective cohort study included consecutive bilateral screening mammograms from women 30 years or older performed from January 1, 2009, to December 31, 2018, across 5 sites of a large academic health system, with follow-up through December 31, 2023, to allow ascertainment of 5-year breast cancer outcomes. A DL risk model applied to standard screening mammograms and radiologist-assessed breast density categorized using the American College of Radiology Breast Imaging Reporting and Data System (BI-RADS) Atlas. Primary outcomes were breast cancer diagnoses within 5 years of mammography and FN screening results, defined as BI-RADS 1 or 2 examinations followed by a cancer diagnosis within 1 year. DL risk scores were stratified as low (<1.7%), intermediate (1.7%-3.0%), or high (>3.0%). Cancer and FN rates were compared across DL risk groups and breast density categories. Discriminatory performance was assessed using the area under the receiver operating characteristic curve (AUROC) and compared using the DeLong test. Among 123 091 mammograms in 67 019 women (median [IQR] age, 58.0 [50.0-67.0] years), 50 974 (41.4%) were classified as dense. The DL model demonstrated significantly higher discriminatory accuracy than breast density in predicting future cancer (AUROC, 0.71 [95% CI, 0.70-0.72] vs 0.53 [95% CI, 0.52-0.54]; P < .001). FN rates increased across DL risk groups (2.1 per 1000 examinations in high-risk vs 1.0 and 0.6 in intermediate and low-risk groups, respectively). Women with dense breasts had higher FN rates than those with nondense breasts (1.7 vs 0.6 per 1000 examinations; P < .001). Adding breast density to the DL model did not improve performance. In this cohort study of screening mammography, a DL risk model outperformed breast density in estimating risk of future breast cancer and stratified FN screening results across risk groups. These findings support transitioning from density-based policy triggers toward more precise image-derived risk models to guide access to supplemental imaging.

Appendiceal adenocarcinoma (AA) is a rare gastrointestinal cancer that frequently presents with peritoneal metastases; the standard of care for resectable peritoneal metastases from AA limited to the peritoneum is cytoreductive surgery (CRS) followed by hyperthermic intraperitoneal chemotherapy (HIPEC). Three serum tumor markers (TMs)-carcinoembryonic antigen (CEA), carbohydrate antigen 19-9 (CA19-9), and cancer antigen 125 (CA125)-may play a role in preoperative and postoperative risk estimation and decision-making in patients undergoing CRS-HIPEC. To evaluate the association of preoperative and postoperative serum TM levels with outcomes in patients with AA or goblet cell adenocarcinoma (GCA) undergoing CRS-HIPEC. This retrospective cohort study was conducted in a single quaternary referral cancer center. Software was used to query the MD Anderson internal patient database of patients with AA or GCA to identify a cohort receiving CRS with or without HIPEC between March 2016 and August 2024, with median postoperative follow-up of 35.6 months (range, 1.4-100.5 months). Data were analyzed from June 2024 to March 2025. Preoperative and postoperative levels of CEA, CA19-9, and CA125. Association of preoperative and postoperative serum TM levels with tumor burden and likelihood of complete CRS, disease-free survival (DFS), and overall survival (OS). A total of 421 CRSs were included in the study, 376 (89.3%) of which were performed in patients with AA (229 [60.9%] in females; median age at surgery, 56 [IQR, 47-64] years; 290 [77.1%] were complete CRS). In AA, greater vs lesser preoperative tumor burden was associated with increased median serum TM levels (CEA: 9.5 [IQR, 3.7-42.3] ng/mL vs 3.0 [IQR, 2.1-5.9] ng/mL; CA19-9: 31.1 [IQR, 10.0-102.3] U/mL vs 15.0 [IQR, 6.1-25.5] U/mL; CA125: 28.7 [IQR, 13.9-58.5] U/mL vs 11.5 [IQR, 8.0-17.3] U/mL; all P < .001), and after CRS vs before, percentages of patients with TM elevation were significantly lower (CEA: 77 of 223 [34.5%] vs 222 of 340 [65.3%]; CA19-9: 45 of 194 [23.2%] vs 117 of 324 [36.1%]; CA125: 13 of 203 [6.4%] vs 98 of 325 [30.2%]; all P < .001). However, complete vs incomplete CRS was associated with normalized TM levels in a greater percentage of patients (55 of 90 [61.1%] vs 7 of 52 [13.5%]; P < .001). Elevated vs normal preoperative TM levels were associated with increased rate of incomplete CRS (30 of 193 [15.5%] vs 1 of 95 [1.1%]; P < .001) and shorter DFS (hazard ratio [HR], 2.30; 95% CI, 1.46-3.64; P < .001) but not shorter OS (HR, 1.36; 95% CI, 0.71-2.60; P = .36). Postoperative TM elevation was associated with shorter DFS (HR, 3.73; 95% CI, 2.33-5.95; P < .001) and OS (HR, 4.10; 95% CI, 2.02-8.31; P < .001) in univariate analyses and also in multivariate analyses (HR, 3.34; 95% CI, 1.44-7.75; P = .005), whereas postoperative normalization of all TMs was associated with improved DFS (HR, 3.54; 95% CI, 2.01-6.23; P < .001) and OS (HR, 6.00; 95% CI, 2.06-17.46; P = .001) in univariate analyses and also in multivariate analyses (HR, 4.21; 95% CI, 1.33-13.35; P = .02). In this cohort study of CRS in patients with AA, elevated serum TM levels were associated with worse outcomes, suggesting that patients with postoperative TM elevation after complete CRS may represent a cohort with residual tumor that requires more cautious surveillance and that both preoperative and postoperative levels of CEA, CA19-9, and CA125 should be assessed in clinical practice.

Depressive symptoms in patients with Parkinson disease (PD) are common and burdensome. High-frequency repetitive transcranial magnetic stimulation (HF-rTMS) targeting the left dorsolateral prefrontal cortex (DLPFC-L) is effective but time intensive, limiting practicality. To evaluate the antidepressant efficacy and neurofunctional effects of the ultra-brief intermittent theta-burst stimulation (iTBS) protocol for patients with PD depression (PD-D) compared with active HF-rTMS and sham stimulation. This triple-arm, randomized, sham-controlled single-center clinical trial was conducted at Xinhua Hospital, Shanghai Jiao Tong University School of Medicine in China from August 1, 2024, to January 31, 2025. Patients with PD aged 50 to 80 years with 24-item Hamilton Depression Rating Scale (HAMD-24) scores of 8 to 20 were randomized 1:1:1 to iTBS, HF-rTMS, or sham iTBS. Outcomes were assessed at baseline, week 1, week 2, and week 6. Data analysis was finalized in February 2026. Ten daily sessions over 2 weeks: active iTBS (3 minutes and 20 seconds), active HF-rTMS (20 minutes), or sham iTBS. The primary outcome was the HAMD-24 score at week 2. Secondary outcomes included anxiety (measured by the 14-item Hamilton Anxiety Rating Scale [HAMA-14]), motor symptoms (measured by the Movement Disorder Society-Unified Parkinson Disease Rating Scale), quality of life (measured by the 8-item Parkinson's Disease Questionnaire [PDQ-8]), and prefrontal hemodynamics (measured using functional near-infrared spectroscopy). Primary analysis followed the principle of intention to treat. Of 54 randomized participants (mean [SD] age, 70.1 [5.3] years; 29 men [53.7%]), 50 (92.6%) completed the trial. Linear mixed-effects models revealed a significant group × time interaction for the HAMD-24 (F6,145 = 4.84; P < .001). At week 2, both active interventions were superior to sham (HAMD-24 score mean difference: iTBS, -4.97 [95% CI, -7.71 to -2.23]; P < .001; and HF-rTMS, -5.73 [95% CI, -8.95 to -2.51]; P < .001). Effects persisted at week 6 (HAMD-24 score mean difference: iTBS vs sham, -6.05 [95% CI, -9.26 to -2.83]; P < .001; and HF-rTMS vs sham, -5.57 [95% CI, -9.36 to -1.78]; P = .002), with no between-group differences. Both interventions improved PDQ-8 scores at week 2 (mean difference: iTBS vs sham, -2.33 [95% CI, -3.33 to -1.33]; P < .001; and HF-rTMS vs sham, -2.43 [95% CI, -4.60 to -0.26]; P = .02). iTBS also alleviated anxiety (mean difference: HAMA-14 score vs sham, -4.04 [95% CI, -7.73 to -0.35; P = .03). Active stimulations increased DLPFC-L activation (estimated adjusted difference: iTBS vs sham, 151.18 [95% CI, 51.24-251.11]; P = .004; and HF-rTMS vs sham, 173.26 [95% CI, 71.92-274.60]; P = .001) and reduced time in low-efficiency connectivity states (iTBS: median change, -0.12 [IQR, -0.29 to 0.02]; false discovery rate-corrected P = .045; and HF-rTMS: -0.12 [IQR, -0.32 to 0]; false discovery rate-corrected P = .02). In this randomized clinical trial of patients with PD-D, the ultra-brief iTBS achieved antidepressant efficacy comparable with that of standard HF-rTMS while markedly reducing treatment time, supporting its use as a pragmatic therapy for PD-D. This study suggests the promise of symptom-stratified neuromodulation for personalized treatment protocols. Chinese Clinical Trial Registry Identifier: ChiCTR2100044421.

Children with acute gastroenteritis-associated vomiting discharged from emergency departments (EDs) have improved outcomes when provided with ondansetron for home use. However, only one-third of children who present with significant vomiting experience ongoing vomiting after discharge. To identify characteristics associated with 3 or more vomiting episodes among pediatric patients within 24 hours of ED discharge. This nonprespecified secondary analysis of a randomized clinical trial of children aged 6 months to less than 18 years presenting to EDs between September 14, 2019, and June 27, 2024, with acute gastroenteritis-associated vomiting and who were followed up for 7 days. A prognostic score was derived using generalized linear mixed models across 10 imputed datasets. Data analysis was performed between May 9, 2025, and February 13, 2026. The primary outcome was 3 or more episodes of vomiting within 24 hours of ED discharge. Secondary outcomes included unscheduled health care revisits, intravenous fluid administration, and hospitalization within 7 days after the ED visit. Of 1030 children enrolled, 977 had follow-up data available and were included in this analysis (median age, 47.0 months [IQR, 22.1-80.1 months]; 493 [50.5%] girls; 925 [89.8%] with complete follow-up data). Eighty of 927 children (8.6%) had 3 or more episodes of vomiting in the 24 hours after ED discharge. In unadjusted analysis, only age 6 months to less than 2 years was associated with ongoing vomiting after discharge (odds ratio [OR], 2.17; 95% CI, 1.37-3.43). In multivariable regression analysis, variables associated with postdischarge vomiting included age 6 months to less than 2 years, symptom duration of 24 to 48 hours, or 10 or more vomiting episodes in the 24 hours preceding the ED visit. In a predictive model, a score of 4 points or more was associated with a 13.6% (95% CI, 9.9%-18.1%) probability of 3 or more vomiting episodes within 24 hours of ED discharge, with a sensitivity of 0.50 (95% CI, 0.39-0.61) and specificity of 0.70 (95% CI, 0.67-0.73). Children with 3 or more vomiting episodes within 24 hours of discharge, compared with those without, were more likely to have an unscheduled health care visit (33 of 80 [41.3%] vs 65 of 846 [7.7%]; difference, 33.6%; 95% CI, 22.6%-44.5%), receive intravenous fluids (9 of 80 [11.3%] vs 15 of 846 [1.8%]; difference, 9.5%; 95% CI, 2.5%-16.5%), and be hospitalized (5 of 80 [6.2%] vs 9 of 846 [1.1%]; difference, 5.2%; 95% CI, -0.2% to 10.5%) within 7 days of discharge. In this analysis of children presenting for ED care with vomiting, younger children and those unwell for 24 to 48 hours with 10 or more episodes of vomiting at presentation were more likely to have persistent vomiting after discharge. Based on these findings, these children are most likely to benefit from being provided ondansetron for home administration. ClinicalTrials.gov Identifier: NCT03851835.

A notable proportion of patients with ankylosing spondylitis (ie, radiographic axial spondyloarthritis [r-axSpA]) experience either inadequate responses or intolerance to available therapies, highlighting the need for additional treatment options that offer sustained disease control. To evaluate the efficacy and safety of vunakizumab, a novel anti-interleukin (IL) 17A monoclonal antibody, in r-axSpA. This randomized, double-blind, placebo-controlled, phase 2 to 3 clinical trial was conducted in 38 hospitals in China. A total of 548 adult patients (aged ≥18 years) with active r-axSpA were enrolled between June 9, 2021, and March 30, 2023. Data were analyzed from November 3, 2023, to January 14, 2024. In phase 2, patients were randomized 2:2:1 to receive a subcutaneous dose of vunakizumab, 120 mg, vunakizumab, 240 mg, or placebo; vunakizumab, 120 mg was determined to be the recommended dose after interim analysis. In phase 3, patients were randomized 2:1 to receive vunakizumab, 120 mg or placebo at weeks 0, 2, 4, 8, and 12; from week 16, all patients received vunakizumab, 120 mg every 4 weeks through week 32. The primary end point was the proportion of patients with improvement of 20% or greater in Assessment of Spondyloarthritis International Society response criteria (ASAS20) at week 16. Secondary end points were ASAS20 at week 32, improvement of 40% or greater in ASAS response criteria (ASAS40) at weeks 16 and 32, improvement of 20% or greater in 5 of 6 ASAS domains (ASAS5/6) at weeks 16 and 32, and changes from baseline at weeks 16 and 32 in Bath Ankylosing Spondylitis Disease Activity Index score, Bath Ankylosing Spondylitis Functional Index score, Bath Ankylosing Spondylitis Metrology Index score, 36-Item Short Form Survey score, and Ankylosing Spondylitis Quality of Life Questionnaire score. During the entire study, 548 patients were randomized (mean [SD] age, 33.0 [8.9] years; 440 [80.3%] male), including 294 receiving vunakizumab, 120 mg and 146 receiving placebo. At week 16, the ASAS20 response rate was significantly higher with vunakizumab, 120 mg vs placebo (193 [65.6%] vs 62 [42.5%], respectively; difference, 23.2% [95% CI, 11.8%-34.0%]; P < .001); the ASAS40 response rate also favored vunakizumab, 120 mg vs placebo (136 [46.3%] vs 35 [24.0%], respectively; difference, 22.3% [95% CI, 13.3%-31.3%]; P < .001). Responses with vunakizumab were sustained through 32 weeks. During the placebo-controlled period, incidence of adverse events (246 [83.7%] vs 119 [81.5%]) were comparable in the vunakizumab, 120 mg and placebo groups. In this randomized clinical trial of patients with r-axSpA, vunakizumab, 120 mg significantly improved signs and symptoms of r-axSpA at week 16 compared with placebo, with sustained efficacy through 32 weeks, and demonstrated a tolerable safety profile. These findings support vunakizumab, 120 mg as a new treatment option for active r-axSpA. ClinicalTrials.gov Identifier: NCT04840485.

Sedatives, commonly administered in the clinical treatment of young children with critical illness, may be harmful to early brain development. To investigate whether sedative choice during critical illness in early childhood is associated with long-term neurocognitive function. This prospective cohort study was conducted among a subset of cognitively appropriate children with acute respiratory failure who were aged 8 years or younger when enrolled in the Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE) cluster-randomized clinical trial conducted in 31 pediatric intensive care units (PICUs) comparing a nurse-implemented, goal-directed sedation protocol with usual care. Patients underwent neurocognitive testing 3 to 8 years after hospitalization at regional neuropsychology testing centers. Neurocognitive testing was conducted from February 16, 2015, to November 27, 2018. Assessors were blinded to the sedation provided. Data were analyzed from September 2022 to March 2026. Critical illness and sedation. The primary outcome was IQ, estimated by the age-appropriate Vocabulary and Block Design subtests of the Wechsler Intelligence Scale. Drug- and dose-dependent associations between sedatives and neurocognitive function were assessed, adjusting for baseline factors and severity and course of critical illness. Neurocognitive testing was performed among 256 children (median [IQR] age, 6.6 [5.4 to 9.0] years). Among 243 children with data, 228 children (93.8%) had age-appropriate global assessment of cognitive function (Pediatric Cognitive Performance Category = 1) at testing. Children were exposed to a median (IQR) of 8 (5 to 14) days of continuous sedation at a median (IQR) age of 1.0 (0.2 to 3.2) years. The mean (SD) estimated IQ was 100.3 (13.2), similar to the published test mean of 100. Mean (SD) estimated IQ at long-term follow-up was lowest in patients receiving an opioid- and benzodiazepine-only strategy (98.3 [11.8]), higher in patients receiving multiple sedative classes not including dexmedetomidine (100.6 [14.5]), and highest in patients receiving multiple sedative classes, including dexmedetomidine (101.9 [13.5]). Controlling for Hollingshead Socioeconomic Status score, severity of illness on PICU admission, and duration of mechanical ventilation, the adjusted mean difference in estimated IQ between the opioid- and benzodiazepine-only vs dexmedetomidine groups was -4.1 (95% CI, -7.3 to -0.9; P = .01). In this study of young children who received more than a week of PICU sedation, the estimated IQ was similar to that of the general population. Children who received an opioid- and benzodiazepine-only strategy scored lower than those who received a strategy that included dexmedetomidine when controlling for socioeconomic status, illness severity, and duration of mechanical ventilation. ClinicalTrials.gov Identifier: NCT02225041.

Undocumented immigrants are more than 5 times as likely as US citizens to be uninsured. Before 2020, undocumented young adults aged 19 to 25 years in California were eligible for restricted-scope Medi-Cal, which only covers emergency services. To examine the association of the California 2020 full-scope Medi-Cal expansion to young adults aged 19 to 25 years regardless of immigration status with coverage outcomes and to assess subgroup differences by race and ethnicity, sex, and age. This cross sectional study included American Community Survey respondents who were noncitizens aged 19 to 25 years before (2016-2019) and after (2021-2022) the policy's implementation in California; the treatment group was compared with California noncitizens aged 26 to 32 years and young adults aged 19 to 25 and 26 to 32 years from 6 comparison states (Arizona, Florida, Illinois, Nevada, New York, and Texas). Analysis was conducted from January 2024 to August 2025. California's 2020 Medi-Cal expansion. Triple difference analysis was used to estimate the association of the California Medi-Cal expansion with health insurance coverage (any, Medicaid, and private coverage) among noncitizens aged 19 to 25 years relative to California noncitizens aged 26 to 32 years and young adults in the 6 comparison states. The sample included 19 773 and 32 515 noncitizen American Community Survey respondents in California aged 19 to 25 years and 26 to 32 years, respectively, and 28 535 and 43 213 individuals aged 19 to 25 years and 26 to 32 years, respectively, residing in comparison states. Baseline weighted percentages for the 19- to 25-year treatment group included 52.1% (95% CI, 51.0%-53.2%) male, 31.9% (95% CI, 30.7%-33.0%) Asian non-Hispanic, 1.8% (95% CI, 1.5%-2.2%) Black non-Hispanic, 54.6% (95% CI, 53.4%-55.9%) Hispanic, 9.7% (95% CI, 8.9%-10.5%) White non-Hispanic, and 2.0% (95% CI, 1.6%-2.3%) other race non-Hispanic. Medi-Cal expansion was associated with a 4.2 (95% CI, 1.3-7.1)-percentage-point increase in Medicaid and a 3.5 (95% CI, 0.2-6.8)-percentage-point increase in any coverage. In subgroup analyses, percentage-point increases in Medicaid were statistically significant for Hispanic young adults (6.7 [95% CI, 2.6-10.9] percentage points), males (3.6 [95% CI, 0.1-7.1] percentage points), females (5.0 [95% CI, 0.7-9.3] percentage points), those aged 19 to 22 years (4.4 [95% CI, 0.7-8.1] percentage points), and those aged 23 to 25 years (4.0 [95% CI, 0.7-7.3] percentage points). In post hoc analyses, the estimates translated to increases in Medi-Cal and any coverage of 24.4 and 20.3 percentage points, or 30 665 and 25 554 young adults, respectively. In this cross-sectional study, the California 2020 Medi-Cal expansion was associated with significant coverage gains. Because the American Community Survey did not distinguish between restricted- and full-scope Medi-Cal, the analysis may have underestimated coverage increases, and further research is warranted to understand the health care and economic costs and benefits of California's expansion.