Category: Nevin Manimala

BMC Sports Sci Med Rehabil. 2026 Jan 9. doi: 10.1186/s13102-025-01518-3. Online ahead of print.

ABSTRACT

PURPOSE: Anterior cruciate ligament (ACL) ruptures represent one of the most severe injuries in professional football, often resulting in long rehabilitation, impaired performance, and increased risk of re-injury. The aim of this study was to investigate whether performance parameters derived from match statistics can serve as early indicators of ACL rupture in professional male football players.

METHODS: A retrospective case-control design was applied. Forty-two male professional football players from the German Bundesliga and 2. Bundesliga with confirmed ACL ruptures between 2016 and 2024 were included, alongside 42 matched controls from the same teams and positions. Match performance data from ten games preceding the injury were analyzed. Parameters included minutes played, total distance covered, number of sprints, maximal speed, pass accuracy, number of duels, and duel success rate. Independent t-tests compared injured and control players across individual matchdays and aggregated intervals (the average values across the last four, three, and two matches before injury). Additionally, odds ratios (OR) with 95% confidence intervals were computed based on upper (≥ 75th percentile) and lower (≤ 25th percentile) quartile thresholds to quantify the relative risk associated with extreme performance values.

RESULTS: Injured players showed higher maximum speed that consistently differentiated them from controls, with significant differences at matchday 2 (p = 0.005, OR = 3.42, 95% CI 1.45-8.06) and across all aggregated intervals (p = 0.015-0.031). Injured players also showed significantly fewer minutes played at matchday 2 before injury (p = 0.046, OR = 2.36, 95% CI 1.01-5.51) and across certain intervals (last four and three matches before injury; p = 0.027-0.044). Analysis of matchdays 5-10 revealed no significant group differences for any performance parameter, confirming that relevant performance changes manifest primarily in the immediate pre-injury period. No significant group differences emerged for distance covered, sprint count, pass accuracy, or duel frequency between ACL injured players and controls.

CONCLUSION: Maximum speed showed the strongest association with ACL rupture risk, with significant differences at matchday 2 (p = 0.005) and across aggregated intervals (the average values across the last four, three, and two matches before injury). Reduced playing time emerged as an additional indicator. Although distance covered, sprint count, and pass accuracy did not reach statistical significance individually, their temporal patterns revealed a predisposing risk constellation: injured players demonstrated reduced cumulative exposure combined with acute high-intensity spikes at matchday 2, declining technical precision, and increased physical confrontation at matchday 1. This suggests ACL injury risk manifests through deterioration of integrated performance capacity under acute load fluctuations rather than isolated thresholds. Multifactorial approaches integrating biomechanical, physiological, and temporal performance patterns are essential for effective ACL injury prevention in professional football.

PMID:41508001 | DOI:10.1186/s13102-025-01518-3

J Orthop Surg Res. 2026 Jan 8. doi: 10.1186/s13018-025-06592-4. Online ahead of print.

ABSTRACT

PURPOSE: To investigate the diagnostic performance of magnetic resonance imaging (MRI)-based signs for meniscus posterior root tears (MPRTs).

MATERIALS AND METHODS: A literature search was performed to identify original studies published prior to May 15, 2025 that evaluated the diagnostic accuracy of MRI-based signs for MPRTs. All meta-analyses were performed using Meta-DiSc 1.4 software and StataMP 18.

RESULTS: This meta-analysis evaluated 9 MRI-based signs across 8 studies (1430 patients, 1,533 MRI examinations). In terms of pooled sensitivity, the cleft sign and ghost sign were ≥ 0.8, while the radial tear sign was only 0.6. The cleft sign and/or truncated triangle sign showed the highest sensitivity (0.91). In terms of pooled specificity, the cleft sign and ghost sign were ≥ 0.85. The radial tear sign showed the highest specificity (0.97). In terms of pooled positive likelihood ratio (PLR), the radial tear sign was the highest (18.56). The cleft sign and ghost sign were ≥ 10. In terms of pooled negative likelihood ratio (NLR), the cleft sign and/or truncated triangle sign was the lowest (0.13). The cleft sign and ghost sign were ≤ 0.21, while the radial tear sign was 0.41. In the area under the summary receiver operating characteristic curve (AUC), the ghost sign was the highest (0.97). The cleft sign and radial tear sign were ≥ 0.9. In the diagnostic odds ratio (DOR), the cleft sign was the highest (85.32). The ghost sign, radial tear sign and the cleft sign and/or truncated triangle sign were all ≥ 50. Subgroup analyses revealed no statistically significant differences (P > 0.05).

CONCLUSION: The cleft sign demonstrated the best overall diagnostic performance. High-sensitivity signs are recommended for initial screening, whereas high-specificity signs are indicated for diagnostic confirmation. The ghost sign and cleft sign, with their high AUC and DOR, serve as core diagnostic criteria.

PMID:41507987 | DOI:10.1186/s13018-025-06592-4

Age Ageing. 2026 Jan 3;55(1):afaf373. doi: 10.1093/ageing/afaf373.

ABSTRACT

BACKGROUND: Family caregivers of persons with dementia experience a substantial caregiver burden. Digital psychological interventions represent a promising approach to mitigating this burden.

OBJECTIVES: This study aims to examine the impact of digital psychological interventions on the caregiver burden of dementia caregivers and investigates potential effect-modifying factors and assesses their effects on depression, self-efficacy and quality of life.

METHODS: This study systematically searched six databases for randomized controlled trials or non-randomized studies of interventions and included studies from database inception to 18 May 2025. Meta-analysis was performed using Review Manager 5.4, and subgroup analysis explored the effects of different intervention duration, formats and technological platforms.

RESULTS: A total of 16 studies involving 750 family caregivers were included. Meta-analysis showed digital psychological interventions significantly reduced caregiver burden [Standardized mean difference (SMD) = -0.21, 95% CI: -0.35 to -0.07; P = .003] and improved self-efficacy (SMD = 0.38, 95% CI: 0.15 to 0.61, P = .001) and quality of life (SMD = 0.59, 95% CI: 0.27 to 0.91, P < .001). But digital psychological interventions have no statistically significant in alleviating depressive symptoms (P = .06). Subgroup analyses revealed that interventions lasting ≤2 months, whether delivered in group or individual formats and implemented via web-based or mobile application platforms, had statistically significant effects on caregiver burden.

CONCLUSION: Digital psychological interventions effectively alleviate caregiver burden and enhance their self-efficacy and quality of life. Future studies should prioritize short-term interventions and develop integrated approaches combining individual and group formats.

PMID:41505195 | DOI:10.1093/ageing/afaf373

JMIR Res Protoc. 2026 Jan 8;15:e79889. doi: 10.2196/79889.

ABSTRACT

BACKGROUND: Rheumatoid arthritis (RA) causes pain, fatigue, joint deformity, disability, and an increased risk for serious sequelae, often despite treatment, in 1.3 million Americans. RA is affected by numerous biopsychosocial determinants, which greatly complicate treatment, including altered efficacy.

OBJECTIVE: The purpose of this study is to examine associations between individual biopsychosocial determinants, diet quality, gastrointestinal (GI) health, and disease activity in adults with RA.

METHODS: This cross-sectional, descriptive study has been approved by the Northern Arizona University Internal Review Board (# 2111208-12). We will include 96 adults with RA recruited from across Arizona using social media and community events (through the Arthritis Foundation) and various primary care and rheumatology practices in Flagstaff and the greater Phoenix metro area. Individual biopsychosocial factors will be measured with a demographic survey and direct measures. The Arizona Food Frequency Questionnaire will measure dietary intake for the past 6 months, and Healthy Eating Index-2020 scores will be calculated from these data. The Automated Self-Administered 24-hour diet recall will measure recent dietary intake. Fecal analyses for gut microbiome diversity and composition and fecal calprotectin will measure current GI health. Disease activity will be measured by the Health Assessment Questionnaire-Disability Index and pain scale, Disease Activity Score of 28 Joints, and hematology results (C-reactive protein and erythrocyte sedimentation rate). In addition to descriptive statistics, hierarchical linear regression will examine hypothesized associations between diet quality, GI health, and disease activity. We hypothesize that individual biopsychosocial determinants will be associated with diet quality, which will be indirectly associated with disease activity through gut microbiome diversity and level of GI inflammation in adults with RA.

RESULTS: This study was funded in February 2024. As of December 19, 2025, a total of 80 individuals have been recruited. Data analysis has not yet commenced at the time of manuscript submission. Study results are expected to be published in fall 2026.

CONCLUSIONS: RA is a complicated disease that impacts millions. Few individuals reach sustained remission, even while following provider recommendations. A better understanding of the various factors that impact this complicated disease has the potential to support changes in research and care that will improve the lives of people with RA. The knowledge gained in this study will provide a foundation to inform future interventional research targeting diet quality to support GI health and decrease RA disease activity. Further, the details of this research plan provide methodological resources for other RA researchers, and research results have the potential to improve communication between rheumatology providers and patients.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/79889.

PMID:41505190 | DOI:10.2196/79889

J Trauma Nurs. 2026 Jan-Feb 01;33(1):60-66. doi: 10.1097/JTN.0000000000000897. Epub 2025 Oct 23.

ABSTRACT

BACKGROUND: Massive transfusion protocol (MTP) activations at rural Level III trauma centers often face blood delivery delays, limited support, and product waste. While MTPs are well described in higher-level centers, their effectiveness and staff perceptions in rural Level III settings are unclear. Process breakdowns at one such center, including staffing gaps, delivery delays, and product waste, prompted implementation of a targeted MTP response system.

OBJECTIVE: This project aims to evaluate the effectiveness of an MTP activation response system in a rural Level III trauma center setting.

METHODS: This quality improvement project, using a descriptive design with qualitative methods, was conducted at two rural Midwestern, US Level III trauma centers within the same health system from August 1, 2023, to February 1, 2024. The population included all interdisciplinary team members participating in MTP activations. The project’s revised MTP activation response system featured centralized dispatcher notifications, new modes of communication, multidisciplinary education, and clarification of team roles and processes. After each activation, project participants received a secure, online, anonymous questionnaire assessing perceived system effectiveness, resource delivery, communication, and documentation. Responses were analyzed using descriptive statistics for quantitative data and narrative analysis for open-ended responses to identify thematic outcomes.

RESULTS: A total of N = 35 team members responded across eight MTP activations using the revised response system, including 16 (46%) nurses, 7 (20%) blood bank staff, 5 (14%) pharmacists, 5 (14%) administrative supervisors, and 2 (6%) physicians. Key barriers included inaccurate paging (50%), communication challenges (62.5%), and rapid infuser issues (50%). Appropriate calcium administration occurred in 87.5% of cases; compliance with documentation was high, with 89% noting unit documentation and 83% order confirmation.

CONCLUSION: Implementing a structured multidisciplinary MTP response system in rural Level III trauma centers improved resource delivery, team coordination, and documentation, although communication and workflow challenges persisted.

PMID:41505189 | DOI:10.1097/JTN.0000000000000897

J Med Internet Res. 2026 Jan 8;28:e80803. doi: 10.2196/80803.

ABSTRACT

BACKGROUND: The rapid growth of user-generated web-based health information increases the complexity of cancer information seeking. One promising strategy for promoting high-quality cancer information consumption is through targeted interventions that are intentionally designed to reach individuals in the web-based spaces they occupy. However, there is a paucity of evidence-based information on the best strategies for designing and implementing web-based health behavior change interventions to improve individuals’ cancer-related knowledge and prevent cancer.

OBJECTIVE: This study aimed to develop and pilot test a theory-based intervention via the web to reduce 6 cancer risk factors among rural emerging adults (EAs) through community-engaged research.

METHODS: This mixed methods evaluation describes the development of a web-based cancer prevention intervention aimed at rural EAs aged 18-26 years in the United States and delivered in Facebook private groups. The intervention was guided by behavior change theory and cocreated with EA and Stakeholder Organization Advisory Boards to ensure relevance, accessibility, and appropriateness. We report on 3 formative surveys, a pilot intervention, protocol development, and the community-engaged process for intervention development. Descriptive statistics were applied to the surveys and pilot intervention baseline results to produce means and SDs using R.

RESULTS: We developed posts (n=400) for a Facebook feed aimed at reducing 6 cancer risk behaviors (unhealthy diet, lack of physical activity, tobacco use, alcohol use, sun exposure, and human papillomavirus infection) with iterative input from the EA and stakeholder advisory boards. Formative surveys with rural EAs (n=297) and a pilot study of the intervention with this population (n=26) were conducted. In the pilot study, the intervention reached participants across rural counties, with sustained engagement (post views=1060, reactions=346, comments=72) over a one-month period. Key modifications to the intervention content and design emerged from both advisory boards, the formative surveys, and the pilot intervention, focusing on using perceived reliable sources and direct links to source material.

CONCLUSIONS: This web-based cancer prevention intervention is scalable and delivers engaging, evidence-informed health information to rural EAs. We offer key insights into the design and implementation of web-based cancer prevention interventions for EAs by describing the resources, timelines, and expertise needed to design and implement the intervention. Considerations for fully engaging EA and community stakeholder partners are presented, and we discuss how their involvement resulted in modifications that strengthened the intervention. Finally, we highlight the importance of theory-based health-behavior messaging, digital messaging skillsets, and platform-tailored dissemination strategies for maximizing web-based intervention acceptability.

TRIAL REGISTRATION: ClinicalTrials.gov NCT05618158; https://classic.clinicaltrials.gov/ct2/show/NCT05618158.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/50392.

PMID:41505184 | DOI:10.2196/80803

JAMA. 2026 Jan 8. doi: 10.1001/jama.2025.25033. Online ahead of print.

ABSTRACT

IMPORTANCE: Ibuprofen is first-line therapy for musculoskeletal pain. However, two-thirds of children experience inadequate pain relief with ibuprofen monotherapy, and the efficacy of additive medications for moderate to severe musculoskeletal pain is unclear.

OBJECTIVE: To determine whether treatment with an opioid (hydromorphone) plus ibuprofen or nonopioid (acetaminophen [paracetamol]) plus ibuprofen decreased pain scores compared with ibuprofen alone.

DESIGN, SETTING, AND PARTICIPANTS: Two randomized, double-masked, placebo-controlled trials were conducted from April 2019 to March 2023 in 6 university-affiliated, tertiary care Canadian pediatric emergency departments. Children aged 6 to 17 years presenting with a nonoperative acute limb injury (<24 hours) and a verbal numerical rating scale (vNRS) pain score of 5 or more out of 10 were enrolled. Date of final follow-up was March 22, 2023.

INTERVENTIONS: The opioid trial randomized participants to a single oral dose of ibuprofen plus hydromorphone, ibuprofen plus acetaminophen, or ibuprofen alone. The nonopioid trial randomized participants to a single oral dose of ibuprofen plus acetaminophen or ibuprofen alone. In all groups, ibuprofen was dosed at 10 mg/kg (maximum, 600 mg). The acetaminophen dose was 15 mg/kg (maximum, 1000 mg), and the hydromorphone dose was 0.05 mg/kg (maximum, 5 mg).

MAIN OUTCOMES AND MEASURES: The primary efficacy outcome was self-reported vNRS pain score at 60 minutes post medication administration (score range, 0 [no pain] to 10 [worst pain]; minimal clinically important difference, 1.5). The primary safety end point was the proportion of children with any adverse event related to study drug administration.

RESULTS: A total of 8098 children were screened for eligibility; 699 were randomized and 653 were included in the efficacy analyses. The opioid trial included 249 children: 110 randomized to ibuprofen plus hydromorphone, 70 to ibuprofen plus acetaminophen, and 69 to ibuprofen alone. The nonopioid trial included 450 children: 225 randomized to a single oral dose of ibuprofen plus acetaminophen and 225 randomized to ibuprofen alone. The mean (SD) age of children in the 2 trials was 11.5 (3.5) years and 47.4% were female. The mean (SD) vNRS score at recruitment was 6.4 (1.8). In pooled analyses, mean (SD) vNRS scores 60 minutes after drug administration were 4.8 (2.6) in the ibuprofen plus hydromorphone group, 4.6 (2.4) in the ibuprofen plus acetaminophen group, and 4.6 (2.3) in the ibuprofen alone group (P = .78). Any adverse event occurred at higher rates in the ibuprofen plus hydromorphone group (28.2%) compared with the ibuprofen plus acetaminophen (6.1%) or ibuprofen alone groups (5.8%). No serious adverse events occurred.

CONCLUSIONS AND RELEVANCE: For children with acute nonoperative musculoskeletal injury, pain scores at 60 minutes after drug administration did not improve with ibuprofen plus acetaminophen or ibuprofen plus hydromorphone compared with ibuprofen alone. Adverse events were 4-fold more frequent with hydromorphone.

TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT03767933.

PMID:41505155 | DOI:10.1001/jama.2025.25033

JAMA Oncol. 2026 Jan 8. doi: 10.1001/jamaoncol.2025.5785. Online ahead of print.

ABSTRACT

IMPORTANCE: Cancer survivors have increased cardiovascular disease (CVD) risk partly due to the toxic effects of cancer therapy. Clonal hematopoiesis of indeterminate potential (CHIP), an age-associated blood disorder caused by somatic variants in blood stem cells, is more prevalent among individuals receiving cancer therapy and increases CVD risk independent of traditional risk factors. It is unknown whether CHIP amplifies therapy-related cardiovascular toxic effects in patients with cancer.

OBJECTIVE: To assess the association between CHIP and CVD risk, accounting for competing risks, among patients with primary solid tumors who received chemotherapy, radiotherapy, or immunotherapy.

DESIGN, SETTING, AND PARTICIPANTS: A cohort study was conducted using BioVU, Vanderbilt University Medical Center’s biorepository linking electronic health records to whole-genome sequencing data from 250 038 participants from 2006 to 2025. In this cohort, participants had a primary solid tumor diagnosis, received chemotherapy, radiotherapy, and/or immunotherapy, and did not have hematologic malignant disease before treatment. Data were analyzed from June 2025 to November 2025.

EXPOSURES: CHIP variants detected via whole-genome sequencing, chemotherapy, radiotherapy, and immunotherapy.

MAIN OUTCOMES AND MEASURES: Time to first cardiovascular event, defined as heart failure, ischemic CVD, or arrhythmia following cancer treatment.

RESULTS: Among 8004 eligible participants (median [IQR] age, 61.9 [52.2-69.9] years; 4385 female individuals [54.8%]) with a primary solid tumor diagnosis, 7438 had no heart failure, 7392 no ischemic CVD, and 6002 no arrhythmia before cancer therapy. Overall, 549 (6.9%) had CHIP. In the propensity score-matched cohort, participants with CHIP had a significantly higher 10-year cumulative incidence of heart failure (20.3%; 95% CI, 16.0%-24.4% vs 14.5%; 95% CI, 13.5%-15.6%; P = .001) and ischemic CVD (25.3%; 95% CI, 20.5%-30.0% vs 18.5%; 95% CI, 17.3%-20.0%; P < .001) compared with those without CHIP. In adjusted Fine-Gray models, CHIP was associated with increased risk of heart failure (subdistribution hazard ratio [sHR], 1.26; 95% CI, 1.02-1.56; P = .03). In an exploratory 24-month landmark analysis, there was a statistically significant interaction between CHIP and intensive chemotherapy (≥7 cycles) on heart failure risk (sHR, 1.02; 95% CI, 1.00-1.04; P = .03).

CONCLUSIONS AND RELEVANCE: In this cohort study, CHIP was associated with increased CVD risk in patients with solid tumors receiving cancer therapy. This finding suggests incorporating CHIP status may improve cardio-oncology treatment of cancer survivors.

PMID:41505144 | DOI:10.1001/jamaoncol.2025.5785

JAMA Netw Open. 2026 Jan 2;9(1):e2553146. doi: 10.1001/jamanetworkopen.2025.53146.

ABSTRACT

IMPORTANCE: Rates of metastatic colorectal cancer (mCRC) are rising among young adults. Disparities by race and ethnicity and neighborhood-level socioeconomic status (SES) among this population are understudied.

OBJECTIVE: To examine the association of race and ethnicity and neighborhood-level SES with mortality among a community-based sample of young adults with mCRC.

DESIGN, SETTING, AND PARTICIPANTS: This cohort study used a large electronic health record-derived database of young adults with cancer treated at 280 community-based US clinics between 2013 and 2021. Eligible patients were young adults aged 18 to 49 years diagnosed with de novo or recurrent mCRC. Patients were followed up until December 31, 2022. Data were analyzed from February 2024 to November 2025.

EXPOSURES: Race and ethnicity and neighborhood-level SES. Neighborhood-level SES was derived using census block group (2010 Census boundaries) and most recent address in the electronic health record. Five-year estimates from the American Community Survey (2015-2019) were used to compute the Yost Index, a composite measure of 7 variables that capture different aspects of neighborhood-level SES.

MAIN OUTCOME AND MEASURE: All-cause mortality and 1-, 2-, and 3-year survival from diagnosis. Survival was defined from date of de novo or recurrent mCRC diagnosis to date of death or December 31, 2022.

RESULTS: A total of 3115 young adults diagnosed with mCRC (mean [SD] age at diagnosis, 42.4 [5.9] years; 122 Asian [3.9%], 424 Black [13.6%], 395 Hispanic [12.7%], 1874 White [60.2%]; 1651 male [53.0%]). Survival differed significantly by race and ethnicity and neighborhood-level SES. At 3 years after diagnosis, Black patients had worse survival (41%; 95% CI, 36%-46%), while Asian (58%; 95% CI, 48%-66%) and Hispanic (53%; 95% CI, 48%-58%) patients had better survival compared with White patients (47%; 95% CI, 45%-49%). For neighborhood-level SES, 3-year survival was 41% (95% CI, 36%-45%) for patients in the lowest compared with 59% (95% CI, 54%-63%) in the highest quintile. In adjusted analyses, neighborhood-level SES was associated with mortality (Q1 vs Q5: hazard ratio [HR], 1.51; 95% CI, 1.24-1.82), while the HR for Black race and mortality was greater than 1 but not statistically significant (HR, 1.08; 95% CI, 0.90-1.31).

CONCLUSIONS: In this cohort study of young adults with mCRC, 3-year survival differed by race and ethnicity and neighborhood-level SES, but only the association between neighborhood-level SES and survival remained statistically significant after adjusting for covariates.

PMID:41505130 | DOI:10.1001/jamanetworkopen.2025.53146

JAMA Netw Open. 2026 Jan 2;9(1):e2553157. doi: 10.1001/jamanetworkopen.2025.53157.

ABSTRACT

IMPORTANCE: The Patient Protection and Affordable Care Act (ACA) requires private health insurers to cover recommended preventive services with no patient cost-sharing, but patients covered by these provisions still incur out-of-pocket (OOP) costs for which they should be exempt. To date, no work has assessed how gaps in enforcing the ACA’s cost-sharing exemption affect patients with chronic conditions, who have higher OOP costs overall, which increases the financial burden from their health care.

OBJECTIVE: To determine the relative incidence, magnitude, and determinants of cost-sharing for preventive care among individuals with chronic conditions compared with individuals without such conditions.

DESIGN, SETTING, AND PARTICIPANTS: This cohort study used propensity score matching of patients insured through their employers or the ACA Marketplaces, using claims and remittance data from Symphony Health Solutions’ Integrated DataVerse from 2017 to 2020. Analysis was completed between November 2024 and November 2025.

EXPOSURE: Presence of ambulatory care-sensitive conditions (ACSCs) compared with no chronic conditions.

MAIN OUTCOMES AND MEASURES: Primary outcomes included the incidence and amount of costs levied for preventive care. Secondary outcomes included the incidence of cost-sharing for preventive care specifically due to service code misclassification and visit complexity.

RESULTS: A total of 1 262 414 patients (800 693 female patients [63.42%]; mean [SD] age at the time of visit, 54.46 [12.40] years) received 5 236 253 preventive services over 1 984 354 unique visits. The likelihood of a preventive service resulting in cost-sharing was significantly greater among patients with ACSCs compared with those without ACSCs (17.91% [95% CI, 17.69%-17.95%] vs 15.64% [95% CI, 15.69%-15.95%]; P < .001). Propensity score-matched models found that individuals with ACSCs had a 19.20% increase (95% CI, 18.87%-19.18%; P < .001) in the probability of facing OOP costs for preventive care, and a 20.69% (95% CI, 19.19%-20.91%; P < .001) increase in expected preventive OOP costs overall.

CONCLUSION AND RELEVANCE: These findings suggest that patients with chronic conditions were more likely to experience cost-sharing for preventive care and had greater expected spending overall. Standardizing insurer practices regarding cost-sharing exemptions can improve equitable access to high-value preventive care.

PMID:41505129 | DOI:10.1001/jamanetworkopen.2025.53157