Nevin Manimala

Eur J Endocrinol. 2026 Mar 13:lvag050. doi: 10.1093/ejendo/lvag050. Online ahead of print.

ABSTRACT

OBJECTIVE: Adiposity rebound is the first rise in BMI that occurs after the initial decrease during infancy. Early adiposity rebound, before age 5, is a risk factor for later obesity and metabolic problems. We investigated adiposity rebound in children with Congenital Adrenal Hyperplasia due to 21-hydroxylase deficiency (CAH).

DESIGN: Longitudinal observational registry study.

METHODS: Height, weight and BMI from patients younger than 20 years in the I-CAH Registry was described by non-linear mixed-effects models. Covariates of glucocorticoid dose, mineralocorticoid dose, 17-Hydroxyprogesterone were assessed on growth and bone age.

RESULTS: A total of 10,261 visits within 573 patients (43.6% male) showed significant variation in age at latest peak height velocity (8.4 years (SD = 3.0) in boys; 9.0 years (SD = 1.6) in girls). Peak height velocity was more blunted in boys (7.7 cm/year (SD = 1.4)) than girls (7.4 cm/year (SD = 1.3)) in comparison to normative values. Adiposity rebound occurred earlier than age 5 years in 82% of the cohort, mean age 3.7 years (SD = 1.3) in boys and 3.9 years (SD = 0.9) in girls. Girls prescribed higher doses of glucocorticoid were associated with heavier weight in adolescence and earlier adiposity rebound. Bone age was increasingly advanced in those prescribed higher doses in both sexes.

CONCLUSIONS: There is a large variation in the timing of adiposity rebound and SITAR-estimated latest peak height velocity in children with CAH. In addition to identifying individuals with CAH who may be at risk of adverse cardiometabolic outcomes these metrics may serve as early surrogate outcomes in future research investigating early-life treatment strategies.

PMID:41823987 | DOI:10.1093/ejendo/lvag050

JAMA Netw Open. 2026 Mar 2;9(3):e260692. doi: 10.1001/jamanetworkopen.2026.0692.

ABSTRACT

IMPORTANCE: An increasing number of older adults living with frailty are undergoing surgery, yet scarce data on postoperative functional recovery, care needs after surgery, and extent of caregiver supports exist.

OBJECTIVE: To characterize older adults’ and caregivers’ recovery experiences in the first 6 months after surgery.

DESIGN, SETTING, AND PARTICIPANTS: This mixed-methods, multicenter, prospective nested cohort study included 17 hospitals in Canada. Participants included adults aged 65 years or older with a Clinical Frailty Scale score of 4 or more, who were recovering after major elective noncardiac surgery between March 16, 2021, and June 13, 2023, and their caregivers.

MAIN OUTCOMES AND MEASURES: Surveys included functional status via basic and instrumental activities of daily living, care needs, and care received or provided. A subset of patients and caregivers were invited to participate in semistructured interviews about their experiences and were analyzed using interpretive descriptive qualitative analysis.

RESULTS: There were 289 individuals, including 204 older adults (mean [SD] age, 72.8 [5.6] years; 108 males [52.9%]) and 85 caregivers (mean [SD] age, 68.2 [12.2] years; 50 females [59.5%]), who participated in surveys, and 63 individuals (43 older adults and 20 caregivers) who participated in interviews. Older adults had a median (range) Clinical Frailty Score of 4 (3-6), indicating mild frailty, and 190 (93.1%) had 1 or more chronic diseases. Caregivers had a median (range) of 2 (0-8) chronic diseases, and 69 (82%) were spouses. Two months postoperatively, 129 of 203 older adults (64%) had more than 1 instrumental activities of daily living impairment, decreasing to 84 of 198 (42%) at 6 months after surgery; 68 of 203 (33%) had more than 1 activities of daily living impairment 2 months postoperatively, and this decreased to 38 of 198 (19%) at 6 months after surgery. Themes related to the recovery experiences were: (1) inadequate patient and caregiver education, preparation for surgery, and discharge; (2) the association of reduced independence with patient and caregivers; (3) the association of surgery with mental health; and (4) postoperative support from the health care team. All participants indicated that they wanted to be better prepared for surgery and discharge.

CONCLUSION AND RELEVANCE: In this mixed-methods cohort study, functional recovery in the first 6 months after noncardiac major elective surgery was associated with daily living impairment for older adults and their caregivers. Targeted interventions including preoperative education, caregiver-inclusive discharge planning (eg, wound-care teaching, how to recognize complications and what to do for support, and more rehabilitation), and early follow-up after discharge may optimize recovery experiences.

PMID:41823967 | DOI:10.1001/jamanetworkopen.2026.0692

JAMA Netw Open. 2026 Mar 2;9(3):e261641. doi: 10.1001/jamanetworkopen.2026.1641.

ABSTRACT

IMPORTANCE: Inappropriate antimicrobial use is a major but modifiable contributor to antimicrobial costs and harms. To address this global threat, many countries have implemented national stewardship programs. However, the cost-effectiveness of such programs targeting primary care physicians remains unknown.

OBJECTIVE: To determine the economic value of an antibiotic audit and feedback (A&F) program from a Canadian public payer perspective.

DESIGN, SETTING, AND PARTICIPANTS: This economic evaluation used data from a randomized clinical trial of primary care physicians in Ontario, Canada, in which a mailed A&F intervention reduced antibiotic prescribing among patients 65 years and older. Trial data were linked with administrative databases to estimate the program costs and savings from reduced antibiotic use, adverse events, and undertreatment harms. A decision model was developed to calculate monetary costs and benefits. Data were collected from January 1 to July 1, 2022, and were analyzed from March 1 to April 1, 2025. All costs are reported in 2024 Canadian dollars.

INTERVENTION: A mailed A&F letter sent to primary care physicians with their antibiotic prescribing rate compared with their peers, with additional messaging about the harms of unnecessary antibiotics.

MAIN OUTCOMES AND MEASURES: Net costs and benefits, return on investment (ROI), and probability of achieving a positive ROI (>1). Uncertainty was explored using probabilistic analysis with 5000 simulations and deterministic sensitivity analyses.

RESULTS: The study included 4879 primary care physicians, of whom 2711 (55.6%) were male, with a mean (SD) of 25.0 (13.3) years since medical school graduation. The program cost was $5.50 per physician and generated $43.03 in savings. The ROI was $8.82 (95% uncertainty interval, $1.32-$22.56) per dollar invested. The probability that the antibiotic A&F program provided an ROI greater than 1 was 93.2%. Scaling the program to all primary care physicians in Ontario would further improve the estimated ROI. Results were robust across sensitivity analyses.

CONCLUSIONS AND RELEVANCE: In this economic evaluation of a mailed antibiotic A&F intervention, the intervention was associated with substantial economic and clinical value. These findings support A&F as a scalable, low-cost component of antimicrobial stewardship programs and highlight its potential to optimize prescribing and reduce antimicrobial resistance.

PMID:41823966 | DOI:10.1001/jamanetworkopen.2026.1641

JAMA Netw Open. 2026 Mar 2;9(3):e261703. doi: 10.1001/jamanetworkopen.2026.1703.

ABSTRACT

IMPORTANCE: Transfers of deceased organ donors from acute care hospitals to specialized donor care units (DCUs) offer operational and outcome advantages; however, current access to DCUs is limited and geographically uneven. Expanding access to DCUs may improve donation system efficiency.

OBJECTIVE: To evaluate the geographic distribution of operating DCUs relative to acute care hospitals and explore how to most efficiently operationalize recommendations that a DCU operate in every donation region.

DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study analyzed deceased organ donor and hospital data captured in the Organ Procurement and Transplantation Network and American Hospital Association survey databases from January 1, 2018, to December 31, 2023. Acute-care hospitals and DCUs operating in the continental US and adult (aged ≥18 years) organ donors with brain death managed in acute care hospitals located in 2203 zip codes were included. The data analysis was performed between October 1, 2024, and December 1, 2025.

EXPOSURES: Geographic location of organ donor hospitals.

MAIN OUTCOMES AND MEASURES: The main outcome was the optimal number of DCUs required to enable transportation of all cohort donors from acute care hospitals to DCUs via ambulance (within a 180-minute drive). The number of additional DCUs needed to operationalize recommendations of a DCU in every donation region was quantified with and without consideration for donation service area boundaries using location-allocation modeling.

RESULTS: Between 2018 and 2023, 53 093 deceased donors met the inclusion criteria (mean [SD] age, 44.3 years [15.0]; 60.0% male). Among the cohort, 61.9% of donors were managed in acute care hospitals within driving distance of 34 operating DCUs. In the current system with distinct donation service area boundaries, an additional 38 DCUs were estimated to provide plausible access to 92.7% of donors. If donation service area boundaries were ignored, 22 new DCUs were estimated to provide a referral facility for a larger proportion of donors (96.5%).

CONCLUSIONS AND RELEVANCE: This cohort study found that despite their reported advantages and consensus endorsement, heterogeneous adoption of DCUs has left a substantial proportion of deceased donors after brain death more than a 180-minute drive from a DCU. Given inefficiencies introduced by donation service area boundaries, opening additional DCUs in acute care hospitals and donor transport across these existing boundaries may be 2 potential approaches to improve system efficiency and donation outcomes.

PMID:41823965 | DOI:10.1001/jamanetworkopen.2026.1703

JAMA Netw Open. 2026 Mar 2;9(3):e261741. doi: 10.1001/jamanetworkopen.2026.1741.

ABSTRACT

IMPORTANCE: Diagnosing urinary tract infection (UTI) in preverbal, pre-toilet trained children is challenging and may lead to unnecessary testing and treatment. UTICalc estimates UTI risk using clinical and laboratory data but has not been prospectively validated.

OBJECTIVES: To prospectively validate UTICalc version 3.0 for predicting UTI and to evaluate its utility in guiding clinical decisions.

DESIGN, SETTING, AND PARTICIPANTS: This prospective diagnostic study was conducted at 2 tertiary care pediatric emergency departments (EDs) in Canada from November 2022 to January 2025. Children aged 2 to 24 months presenting with measured fever (≥38.0 °C) were enrolled. Exclusions included congenital urinary tract abnormalities, immunosuppression, current antimicrobials, or prior enrollment. Participants were followed up to identify UTIs; urine culture results were reviewed within 48 hours, and phone or email follow-up was completed within 2 weeks for those without testing at the index visit.

EXPOSURE: UTICalc-predicted probability of UTI.

MAIN OUTCOMES AND MEASURES: The primary outcome was UTI, defined as positive urinalysis and significant uropathogen culture growth. The primary analysis examined discriminative performance using area under receiver operating characteristic curve (AUROC). Secondary analyses included calibration (calibration plots, slope, Brier score) and clinical utility (net benefit analysis, comparison with clinician practice).

RESULTS: Among 2561 included participants (1212 [47%] female; 1326 [64%] younger than 12 months), 111 children (4%) were classified as having a UTI. In the full sample, 2256 (88.1%) had urine testing and/or provided follow-up data. The clinical model AUROC was 84.1% (95% CI, 80.4%-87.9%). At a 2% UTI risk threshold, sensitivity was 96.4%, and specificity was 34.1%; at a 5% risk threshold, sensitivity was 82.0%, and specificity was 73.8%. The clinical and dipstick model AUROC was 95.3% (95% CI, 93.3%-97.4%), with 94.0% sensitivity and 86.9% specificity at 5% risk. The sensitivity and specificity for clinicians were 98.2% and 57.3%, respectively. Calibration slopes were 0.11 (95% CI, 0.09-0.13) and 0.06 (95% CI, 0.05-0.07) and Brier scores were 0.04 (95% CI, 0.03-0.05) and 0.05 (95% CI, 0.04-0.06) for the clinical and clinical and dipstick models, respectively. Decision curve analysis showed both models were associated with positive net benefit across a range of risk thresholds.

CONCLUSIONS AND RELEVANCE: In this cohort study of 2561 febrile children aged 2 to 24 months presenting to the ED, UTICalc showed strong diagnostic performance, especially with dipstick results. While it did not outperform experienced clinicians, it offered a useful, evidence-based adjunct for guiding urine testing decisions, supporting efficient care in the pediatric ED.

PMID:41823964 | DOI:10.1001/jamanetworkopen.2026.1741

JAMA Netw Open. 2026 Mar 2;9(3):e261796. doi: 10.1001/jamanetworkopen.2026.1796.

ABSTRACT

IMPORTANCE: Failure to account for the full complexity and costs of high-need populations in the risk-adjusted capitated payment model for Medicare Advantage (MA) plans may create financial disincentives for plans to invest in comprehensive care for affected beneficiaries, potentially exacerbating health disparities.

OBJECTIVE: To evaluate the association of reinstatement of Alzheimer disease and related dementias (ADRD) hierarchical condition categories (HCCs) into the MA risk-adjusted payment model in 2020 with access, affordability, and quality of care for beneficiaries with ADRD.

DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study examined a nationally representative sample of MA beneficiaries from the Medicare Current Beneficiary Survey (2015-2022). Beneficiaries with ADRD and those without ADRD but with comparable neurological diseases (stroke, paralysis, or Parkinson disease) before and after 2020 were included. Data analyses were performed between January and December 2025.

EXPOSURES: Reinstatement of the ADRD HCC into the MA risk adjustment formula in 2020.

MAIN OUTCOMES AND MEASURES: Primary outcomes were accessibility of needed care, medical financial burden, satisfaction with specialist access, and satisfaction with quality of care. These outcomes were assessed using a difference-in-differences model to compare changes between the treatment and control group before and after the inclusion of ADRD HCCs in the MA risk adjustment model in 2020.

RESULTS: Among 5353 MA beneficiary observations (1239 [23.1%] aged 65-74 years; 3127 [58.4%] aged ≥75 years; 1785 male [33.3%]), 1629 (30.4%) reported a diagnosis of ADRD, and 3724 (69.6%) did not report an ADRD diagnosis. Compared with MA beneficiaries without ADRD, those with ADRD reported lower rates of difficulty accessing care (142 beneficiaries [8.7%] vs 394 beneficiaries [10.6%]) and medical financial burden (235 beneficiaries [19.3%] vs 740 beneficiaries [25.1%]), but slightly lower rates of satisfaction with specialist access (1384 beneficiaries [90.8%] vs 3267 [92.7%]) and care quality (1495 beneficiaries [92.8%] vs 3414 beneficiaries [93.0%]). Reintroducing ADRD HCCs into the MA risk-adjusted payment model was associated with a 6.62 percentage-point decrease in reporting any troubles accessing needed care (β = 0.06; 95% CI, -0.11 to -0.02; P = .005) and a 9.20 percentage-point decrease in reporting any medical financial burden (β = -0.09; 95% CI, -0.16 to -0.02; P = .009) among MA beneficiaries with ADRD. No significant association was observed for satisfaction with specialist access or with quality of care among MA beneficiaries with ADRD.

CONCLUSIONS AND RELEVANCE: In this cross-sectional study of MA beneficiaries, reintroducing ADRD HCCs into the MA risk adjustment model was associated with improved care access and reduced financial burden among MA beneficiaries with ADRD. These findings suggest that risk adjustment that better reflects the costs of chronic, complex conditions may better align MA plan incentives with the needs of high-need populations and promote care equity.

PMID:41823963 | DOI:10.1001/jamanetworkopen.2026.1796

JAMA Netw Open. 2026 Mar 2;9(3):e260679. doi: 10.1001/jamanetworkopen.2026.0679.

ABSTRACT

IMPORTANCE: The US Centers for Disease Control and Prevention (CDC) define health equity as “the state in which everyone has a fair and just opportunity to attain their highest level of health.” Achieving this, according to the CDC, requires sustained efforts to address longstanding and contemporary inequities, reduce social and economic obstacles to care, and eliminate preventable differences in health and health care outcomes. Few operational models currently exist to support clinical teams in navigating health equity factors in clinical settings. The Healthcare Equity Consult Service (HECS) was established to assess concerns that contextual or interpersonal factors, including potential bias, may be shaping patient care and to provide structured support to patients, families, and clinical teams.

OBSERVATIONS: This report describes HECS consults conducted from August 2022 to March 2024 across 3 hospitals within an academic medical center in the US. Consults were referred by clinicians, patients, or families to assess equity-related or contextual interpersonal factors during hospitalization. HECS assessments followed a structured, real-time process that included medical record review, patient interviews, conversations with family members, and care team briefings and facilitated interventions to mitigate any potential systemic barriers, communication breakdowns, or perceived bias. Illustrative cases reflected themes in which patients, families, or clinical teams perceived that contextual factors might be shaping care processes, caregiver participation, or trust during clinical encounters. HECS interventions included direct engagement with patients, families, and health care teams to support equitable care. HECS provided real-time recommendations and coaching to clinical care team members regarding perceived biases and contextual factors relevant to patient care. In some instances, these recommendations informed subsequent review or refinement of institutional policies and care processes.

CONCLUSIONS AND RELEVANCE: The HECS model offered a promising strategy for embedding equity-centered interventions into acute care delivery. HECS recommendations leveraged multidisciplinary expertise in response to patient experiences and an acknowledgment of societal barriers with a focus on equitable solutions. These recommendations were incorporated into treatment plans and informed institutional efforts to review and refine clinical practice and policies.

PMID:41823962 | DOI:10.1001/jamanetworkopen.2026.0679

JAMA Health Forum. 2026 Mar 6;7(3):e260078. doi: 10.1001/jamahealthforum.2026.0078.

ABSTRACT

IMPORTANCE: Many US cities track firearm violence with annual homicide counts, which may not capture prevention gains, nonfatal injury trends, and stretches of peace. Metrics that quantify days without shootings provide an opportunity to communicate resilience and guide action. To provide a fuller picture, we introduce 4 novel metrics-shooting-free days (SFDs), shooting death-free days (SDFDs), consecutive shooting-free days (CSFDs), and multiple shooting-free days (MSFDs)-that, to our knowledge, have not previously been calculated across major US cities.

OBJECTIVES: To introduce, compute, and compare the 4 novel metrics across the 10 largest US cities from 2015 through 2024 and to test temporal trends.

DESIGN, SETTING, AND PARTICIPANTS: Repeated cross-sectional, time-series analyses of daily gun violence incidents measured in 10 US cities with populations exceeding 1 million using Gun Violence Archive data to construct city-day observations from all fatal and nonfatal shooting incidents recorded between January 1, 2015, through December 31, 2024. Linear regressions were used to estimate annual trends. Data were analyzed from June 2025 through January 2026.

EXPOSURES: Calendar year and city, operationalized as city-year panels derived from daily counts of persons shot (killed or injured).

MAIN OUTCOMES AND MEASURES: SFDs are defined as days per year with no shooting incidents; SDFDs, days with no shooting deaths; CSFDs, maximum number of consecutive days per year with no shooting incidents; and MSFDs, days with fewer than 2 people shot. Outcomes were computed per city per year and calculating the mean across years.

RESULTS: Of the 10 cities, Chicago had the lowest means (1.6 SFDs, 86.9 SDFDs, 0.6 CSFD, and 9.6 MSFDs per year) whereas San Diego had the highest (291.5 SFDs, 337.6 SDFDs, 24.2 CSFDs, and 347.3 MSFDs). A pronounced pullback occurred from 2019 through 2021. Phoenix and Dallas-Fort Worth had significant declines in all 4 metrics. Overall trends were significantly downward: -4.79 SFDs per year (P < .05), -4.50 SDFDs per year (P < .05), -0.30 CSFDs per year (P < .05), and -8.37 MSFDs per year (P < .01). Jacksonville, was the only city to show a significantly improved metric, in MSFDs (0.84 days per year; P < .05).

CONCLUSIONS AND RELEVANCE: These novel metrics highlight periods of success and safety rather than focusing on negative outcomes. Metrics varied widely, worsened overall during the study decade, and highlighted cities with policies and practices that could be replicated. Incorporating shooting-free metrics into public dashboards can motivate communities, sharpen accountability, and guide interventions in US cities.

PMID:41823961 | DOI:10.1001/jamahealthforum.2026.0078

JAMA Health Forum. 2026 Mar 6;7(3):e260108. doi: 10.1001/jamahealthforum.2026.0108.

ABSTRACT

IMPORTANCE: The Global Burden of Disease (GBD) reports widely used estimates of mortality and disability-adjusted life-years (DALYs) and related risk factors. However, the overall reliability of these estimates between GBD iterations has not been assessed.

OBJECTIVE: To evaluate the instability and inconsistency of GBD risk factor estimates for mortality and DALYs across GBD iterations.

DATA SOURCES: GBD risk factor collaboration estimates extracted from the published tables of GBD iterations and the Institute for Health Metrics and Evaluation repository.

STUDY SELECTION: GBD risk factor collaboration publications published for 2010 through 2023.

DATA EXTRACTION AND SYNTHESIS: Death and DALY estimates were manually extracted by 1 reviewer with independent validation of a random sample of 100 by another with no discrepancies. Risk factor naming was harmonized across iterations to ensure comparability; those with inconsistent definitions were excluded.

MAIN OUTCOMES AND MEASURES: Fluctuations were calculated for numbers of deaths and DALYs for each risk factor across GBD iterations during the study period (2010-2023) and between the original and subsequently revised estimates for each year (1990-2021). Differences were expressed as a ratio of the minimum to maximum range to the mean (R:M) and coefficient of variation. Detail analyses assessed diet and low physical activity. Point estimates were compared to the previous iterations’ estimates 95% uncertainty intervals (95% UI) for GBD 2019, 2021, and 2023.

RESULTS: Across GBD iterations from 2010 to 2023, the median (range) R:M was 0.8 (0-3.8) for deaths, and 0.7 (0.1-3.3) for DALYs. Level 2 dietary and child and maternal malnutrition death estimates showed high instability (R:M >1 for 9 of 16 and 4 of 8 risks, respectively). When comparing original estimates with GBD 2019, 2021, and 2023 estimates for the same years, the median R:M was 0.4 (0-2.9) for both deaths and DALYs. The coefficient of variation was greater than 0.2 for 336 of 675 death estimates (50%). Specifically, 70% to 96% of point estimates for red meat, sugar-sweetened beverages, fruits, vegetables, and seafood omega-3 fatty acids in GBD 2021 fell outside the GBD 2019 95% UI. In GBD 2023, only diet high in trans fats had more than half of point estimates outside the GBD 2021 95% UI.

CONCLUSIONS AND RELEVANCE: This meta-epidemiological assessment indicates that GBD estimates are substantially unstable, particularly for behavioral risks, making them unlikely to simply reflect genuine changes over time, and warranting caution in interpretation.

PMID:41823958 | DOI:10.1001/jamahealthforum.2026.0108

JACC Clin Electrophysiol. 2026 Feb 26:S2405-500X(26)00125-8. doi: 10.1016/j.jacep.2026.01.050. Online ahead of print.

ABSTRACT

BACKGROUND: Although ventricular arrhythmias (VAs) are common after left ventricular assist device (LVAD) implantation, the features of early electrical storm (ES) remain poorly characterized.

OBJECTIVE: This study aimed to evaluate the incidence and clinical impact of early ES in LVAD recipients.

METHODS: This international, multicenter, retrospective study included 1,309 recipients of LVADs implanted between 2006 and 2019. Early ES was defined as ≥3 sustained VA episodes within 24 hours during the first 30 days’ postimplantation. The primary outcome was 3-month all-cause mortality. Secondary endpoints included 3-month cardiac mortality and early (≤30 days) right ventricular (RV) failure.

RESULTS: Early ES occurred in 56 patients (4.3%), with a median onset at 5 days’ postimplantation. Patients with early ES experienced higher 3-month all-cause mortality (adjusted HR [aHR]: 3.09; 95% CI: 1.91-5.01; P < 0.01) and increased early RV failure (aHR: 2.05; 95% CI: 1.10-3.92; P = 0.03). Notably, early VA without ES showed no prognostic impact. Multivariable analysis identified 4 independent predictors of early ES: pre-LVAD RV S’ wave ≤9.5 cm/s (aHR: 2.25; 95% CI: 1.23-4.14), heart failure duration of ≥5 years (aHR: 2.41; 95% CI: 1.10-5.28), history of VAs (aHR: 4.43; 95% CI: 2.21-8.87), and prior mechanical circulatory support (aHR: 6.40; 95% CI: 2.12-19.33). The EarlyES-LVAD score, based on these variables, showed good discrimination (C-statistic 0.75) and stratified patients into low-risk (score 0-1), intermediate-risk (score 2-3), and high-risk (score 4-6) groups, with corresponding early ES rates of 1.1%, 3.9%, and 12.4%.

CONCLUSIONS: Early ES, but not isolated early VAs, is associated with substantially worse outcomes in LVAD recipients. The EarlyES-LVAD score enables practical risk stratification, facilitating targeted therapeutic interventions in high-risk patients.

PMID:41823945 | DOI:10.1016/j.jacep.2026.01.050