Category: Statistics

J Neurosurg. 2026 Jul 3:1-11. doi: 10.3171/2026.1.JNS25467. Online ahead of print.

ABSTRACT

OBJECTIVE: Extent of resection (EOR) has previously been demonstrated to have an impact on survival in patients with glioblastoma (GBM). However, with the World Health Organization (WHO) 2021 reclassification of GBMs based on IDH-mutation status, patients with “IDH-mutant GBMs,” who typically survive long term, were reclassified as WHO grade 4 IDH-mutant astrocytomas and removed from the GBM taxonomy. Therefore, it is unknown whether the previously reported impact of resection on survival was a false-positive result due to the inclusion of the less aggressive IDH-mutant tumors in previous datasets. This study aimed to determine the extent to which EOR remains an independent predictor of survival in patients with WHO 2021 GBM after the reclassification of IDH-mutant grade 4 astrocytomas.

METHODS: All cases of GBM tumors (based on the pre-2021 GBM classification) that were newly diagnosed between 2005 and 2021 were identified in our institutional database and subsequently reclassified based on the updated WHO 2021 criteria using IDH status. Multivariable statistical analyses of demographic information, survival time, and EOR based on volumetric MRI were performed to determine the independent predictors of survival for the whole group of patients and for IDH-wildtype GBM patients exclusively. Additional analyses were performed to identify an EOR threshold for improvement in survival.

RESULTS: Of the 523 tumors classified as GBM based on the pre-2021 taxonomy, 52 (9.9%) cases were reclassified as WHO grade 4 IDH-mutant astrocytomas, and the median survival of patients in this group was 7.9 years, whereas median survival of the IDH-wildtype GBM patients was 1.4 years. Multivariate analyses of the whole group demonstrated that IDH-mutant astrocytomas were associated with reduced hazard of death. In both the whole group (n = 523) and in IDH-wildtype GBMs (n = 471), higher EOR of the contrast-enhancing (CE) tumor was associated with reduced hazard of death, whereas older age or male sex was associated with increased hazard of death. Because most patients (90%) had high EOR values (> 81%), a statistically meaningful EOR threshold could not be established.

CONCLUSIONS: These analyses demonstrated that EOR of the CE tumor is an independent predictor of survival and that greater EOR is associated with improved survival in WHO 2021 IDH-wildtype GBMs even after excluding grade 4 IDH-mutant astrocytomas. However, an absolute EOR threshold below which resection did not improve survival could not be established, raising concerns about prior cutoff assessments.

PMID:42398118 | DOI:10.3171/2026.1.JNS25467

J Neurosurg. 2026 Jul 3:1-10. doi: 10.3171/2026.2.JNS251791. Online ahead of print.

ABSTRACT

OBJECTIVE: The purpose of the present study was to establish a reproducible 2-vessel occlusion (2VO) rat model combined with encephalomyosynangiosis (EMS) to investigate angiogenic and proteomic mechanisms of indirect cerebral revascularization as a basis for further study in order to improve angiogenesis and cognition.

METHODS: Fifteen rats underwent 2VO of the bilateral common carotid arteries 1 week apart. At the time of the second occlusion, 10 animals underwent EMS while 5 animals received a sham surgery. Adequate hypoperfusion was considered established if the cerebral blood flow decreased to 40% of baseline. Six weeks after surgery, reperfusion outcomes were assessed with the Longa model, novel object recognition, immunohistochemical analysis, and proteomic analysis.

RESULTS: Animals that underwent EMS surgery demonstrated minimal neurological deficits on the Longa model, and EMS animals spent more time with both the old (mean 16.08 seconds vs 8.07 seconds) and novel (18.21 seconds vs 10.84 seconds) objects, suggesting that the EMS animals overall spent more time exploring in both scenarios compared to the 2VO animals that were more sedentary. Immunohistochemical analysis revealed evidence of increased angiogenesis in tissue specimens collected from the experimental cohort. Proteomic analysis showed that the EMS mechanism of action likely alters metabolism, notably by stimulating aerobic respiration, reducing neutrophil-mediated neuroinflammation, altering synapses, reorganizing cytoskeletal protein binding, and activating MAPK/ERK signaling through L1CAM activation.

CONCLUSIONS: Establishing a 2VO and EMS rat model lays the groundwork for future research across laboratories to explore novel strategies for enhancing neovascularization, ultimately contributing to improved therapeutic approaches for patients with moyamoya disease and other vaso-occlusive cerebrovascular disorders.

PMID:42398107 | DOI:10.3171/2026.2.JNS251791

Aging Ment Health. 2026 Jul 3:1-10. doi: 10.1080/13607863.2026.2696019. Online ahead of print.

ABSTRACT

AIM: This study examined the relationships among fear of aging, engagement in healthy aging behaviors, and successful aging, and explored whether behavioral engagement moderates the association between fear of aging and successful aging.

METHODS: A cross-sectional correlational study was conducted with 348 adults aged 50 years and older in Türkiye. Data were collected using the Personal Information Form, Successful Aging Scale, Engagement in Healthy Ageing Scale, and Fear of Old Age Scale. Descriptive statistics, Pearson correlation, linear regression, and moderation analyses (PROCESS Model 1) were performed.

RESULTS: Engagement in healthy aging behaviors was strongly associated with successful aging (r = 0.701, p < 0.001) and significantly predicted successful aging (β = 0.701, p < 0.001), explaining 49.1% of the variance. Fear of aging showed a weak positive association with successful aging (r = 0.178, p < 0.05) but was unrelated to engagement in healthy aging behaviors. Behavioral engagement did not moderate the relationship between fear of aging and successful aging.

CONCLUSIONS: Engagement in healthy aging behaviors appears to be a key determinant of successful aging, whereas fear of aging has a limited influence and does not promote behavioral engagement. These findings support interventions that encourage active health-promoting behaviors to foster successful aging.

PMID:42398096 | DOI:10.1080/13607863.2026.2696019

Br Med Bull. 2026 Jul 3;159(1):ldag019. doi: 10.1093/bmb/ldag019.

ABSTRACT

BACKGROUND: The routine use of augmentation in the surgical management of primary acute Achilles tendon rupture remains controversial. Biological, mechanical, and synthetic augmentation strategies have been adopted in clinical practice, yet their superiority over standard repair has not been established.

SOURCES OF DATA: A narrative review of peer-reviewed comparative studies, randomized controlled trials, systematic reviews, and meta-analyses retrieved from PubMed and MEDLINE, supplemented by the authors’ clinical expertise.

AREAS OF AGREEMENT: Standard surgical repair of acute Achilles tendon rupture, whether open or minimally invasive, reliably achieves high patient satisfaction, restoration of function, and acceptable return-to-sport rates. Patient-reported outcome measures and re-rupture rates are consistently comparable between augmented and non-augmented repairs across available randomized and controlled studies.

AREAS OF CONTROVERSY: Individual studies have occasionally reported statistically significant improvements in surrogate parameters following augmentation, but these rarely exceed minimally clinically important difference thresholds. Complication rates may be higher with augmentation, and endoscopic flexor hallucis longus transfer for acute ruptures has been associated with elevated re-rupture risk.

GROWING POINTS: Minimally invasive percutaneous repair techniques continue to evolve and provide reliable outcomes without augmentation. The intrinsic regenerative capacity of the Achilles tendon remains the dominant determinant of outcome regardless of operative strategy.

AREAS TIMELY FOR DEVELOPING RESEARCH: Well-powered randomized controlled trials with patient-centered outcomes are needed to evaluate whether any augmentation strategy offers clinically meaningful benefit in defined subgroups, such as patients with pre-existing tendinopathy, delayed presentation, or large-gap defects.

PMID:42398081 | DOI:10.1093/bmb/ldag019

BJS Open. 2026 Jul 3;10(4):zrag078. doi: 10.1093/bjsopen/zrag078.

ABSTRACT

INTRODUCTION: The single-stapling technique (SST) is an alternative to the conventional double-stapling technique (DST), particularly in low rectal surgery. This systematic review and meta-analysis compared anastomotic leak (AL) between SST and DST.

METHODS: A systematic review of the PubMed/MEDLINE, Google Scholar®, and Scopus databases was conducted in accordance with PRISMA guidelines from inception through December 2025. The primary outcome of interest was AL. A random-effects meta-analysis was used to compare AL, blood loss, operative time, and length of hospital stay between SST and DST. Risk ratios (RRs) were calculated for dichotomous outcomes and mean differences or standardized mean differences were calculated for continuous outcomes. Sensitivity and subgroup analyses were conducted according to surgical approach. Risk of bias was assessed, and the certainty of the evidence for AL was evaluated using the GRADE framework.

RESULTS: Of 448 articles screened, 14 were included (2 randomized, 12 observational studies), comprising 1326 patients in the SST group and 1720 in the DST group. SST was associated with a significantly lower risk of AL than DST (RR 0.61; 95% confidence interval 0.42 to 0.90; P = 0.012), with moderate heterogeneity. Sensitivity analysis excluding studies with zero events yielded consistent results. Subgroup analyses showed no difference in AL for open intracorporeal SST compared with DST, a trend toward benefit with minimally invasive intracorporeal SST compared with DST, and a pronounced reduction in AL with transanal SST compared with DST.

CONCLUSIONS: Although the causes of AL are multifactorial, with respect to the stapling technique, SST was associated with a lower risk of AL than DST, and this effect was primarily driven by transanal SST. However, the certainty of evidence is low, and ongoing prospective studies will better define the role of SST.

PMID:42398078 | DOI:10.1093/bjsopen/zrag078

JMIR Form Res. 2026 Jul 3;10:e81355. doi: 10.2196/81355.

ABSTRACT

BACKGROUND: Digital health data and infrastructure facilitate rapid analysis to provide actionable data, thereby fulfilling the principles of a learning health system. In response to a report from the UK Medicines and Healthcare Products Regulatory Agency (MHRA), a rapid service evaluation was carried out to identify patterns of modified-release (MR) opioid use after elective surgery.

OBJECTIVE: We aimed to describe the prescribing patterns of MR opioids, methods to repurpose existing infrastructure, and the experience of collaboration between clinical and research teams using shared data pipelines.

METHODS: A retrospective case-control study was conducted at a tertiary care organization across multiple hospital sites in London, United Kingdom. Prescription and administration data for adult patients undergoing elective surgery between March 31, 2019, and June 20, 2025, were extracted from a standardized research data pipeline within 4 weeks of the publication of the MHRA report. Patients were screened for MR opioid prescriptions in the postoperative period and at hospital discharge. Counts and proportions of encounters in which MR opioids were administered or prescribed were evaluated across the study period. Reflections on the application of the infrastructure for this purpose were also documented.

RESULTS: Of 126,882 elective surgeries screened, 102,879 (81.1%) met the eligibility criteria. Over the study period, patients received a new MR opioid prescription after 7525 (7.3%) of the 102,879 eligible encounters, with 2438 (2.4%) encounters receiving a new MR opioid prescription at hospital discharge. Postoperative administration of MR opioids and prescribing at discharge have declined since 2020. As a result of this study, a new context-aware alert system was developed to monitor and reduce MR opioid prescribing in this surgical cohort. Reflections on the implementation experience demonstrated how collaboration between clinical and research teams in conjunction with integrated and seamless research pipelines allowed rapid knowledge generation. Key issues raised were the difficulty of validation between parallel data extraction systems and how the two different teams compared nonequitable data points and results.

CONCLUSIONS: Mature digital and analytical infrastructure within health care institutions can enable swift evaluation of local practices in the context of national medication safety alerts. This can shorten action response times and improve patient care but requires close collaboration between clinicians and research teams. Shared infrastructure between teams across the learning health system improves data quality and provides easy access to the key users. Further work is needed to understand the benefits and challenges of infrastructure built for other use cases and the effectiveness of the intervention.

PMID:42398067 | DOI:10.2196/81355

JMIR Form Res. 2026 Jul 3;10:e83548. doi: 10.2196/83548.

ABSTRACT

BACKGROUND: Determining the appropriate dosage of pediatric occupational therapy, physical therapy, and speech-language pathology services is important when supporting families of children with disabilities. However, therapy dosage is inconsistently reported, and caregiver-delivered practice between sessions is rarely documented. Ecological momentary assessment (EMA) offers a method to capture caregiver practice in real time and to examine factors that influence it.

OBJECTIVE: This study aims to pilot the use of EMA to measure caregiver practices between therapy sessions and to compare EMA-reported practices with caregiver recall.

METHODS: This pilot prospective cohort study used convenience sampling to recruit caregivers of children receiving therapy services. During September 2024, participants completed a confidential baseline Qualtrics survey in their homes, which included recall of home practice from the previous week. Participants were then invited to complete 30 days of EMA logging of daily practice. Five participants enrolled in the EMA phase, which began 24 to 72 hours after baseline survey completion and took place during October and November 2024. Semistructured follow-up interviews were conducted immediately after the 30-day EMA period.

RESULTS: Of the 34 survey participants, 5 continued to the EMA phase, contributing 150 days of data, with 82 completed entries (82/150, 55%). Caregivers primarily completed EMA logs on days when practice occurred; missing entries were coded as zero practice based on caregiver reports. Recalled practice averaged 4.5 (SD 5.65) bouts/day and 11.6 (SD 6.35) minutes/bout, totaling 71.2 (SD 121.02) minutes/day. EMA-reported practice across all days (n=150) averaged 2.7 (SD 4.39) bouts/day and 6.5 (SD 6.45) minutes/bout, totaling 23.2 (SD 14.12) minutes/day, which was substantially lower than recalled estimates. On days when practice was reported (n=82), EMA-documented practice averaged 5.2 (SD 3.28) bouts/day and 6.5 (SD 6.45) minutes/bout, totaling 23.9 (SD 14.72) minutes/day. Variability in recalled practice was high (mean 71.19, SD 121.02 min/d). Caregivers described practice as occurring in short, frequent bouts embedded within daily routines, with routine integration, child engagement, and recall of therapist strategies identified as key facilitators.

CONCLUSIONS: Caregiver-delivered practice occurred in short, frequent bouts integrated into daily routines. EMA-reported practice was substantially lower than caregiver recall, suggesting that retrospective recall and prospectively reported EMA data may differ substantially. These findings highlight the importance of teaching strategies that are brief, engaging, and easily incorporated into daily routines. Despite the small sample, EMA was acceptable to a subset of caregivers who completed participation; however, substantial attrition between survey enrollment and EMA initiation suggests significant feasibility and participation barriers that warrant further investigation.

PMID:42398065 | DOI:10.2196/83548

JMIR Form Res. 2026 Jul 3;10:e75251. doi: 10.2196/75251.

ABSTRACT

BACKGROUND: Virtual reality (VR) is increasingly used for adjunctive relaxation training in psychiatric care. However, evidence remains limited among hospitalized patients with depressive disorders, particularly in routine inpatient settings in China, and little is known about whether improvement varies by session frequency.

OBJECTIVE: This retrospective study examined whether adjunctive VR-based relaxation training was associated with changes in depressive and anxiety symptoms among inpatients with depressive disorders and whether improvement differed by session frequency.

METHODS: We conducted a retrospective, nonrandomized natural-group comparison using complete anonymized medical records from patients hospitalized in Lishui Second People’s Hospital between January 1 and December 31, 2022. Patients met International Classification of Diseases, Tenth Revision (ICD-10) diagnostic criteria for depressive episodes or recurrent depressive disorders and were screened using predefined criteria. The analytic sample included 133 inpatients: 63 (47.4%) received adjunctive VR-based relaxation training plus usual care and 70 (52.6%) received usual care only. Usual care included pharmacotherapy and physiotherapy. The VR intervention consisted of 25-minute immersive relaxation sessions delivered approximately 3 times per week. Symptoms were assessed at admission and discharge using the 17-item Hamilton Depression Scale and Hamilton Anxiety Rating Scale. Response was defined as a reduction of 50% or more from baseline, and remission was defined as a total score of 7 or less. Baseline characteristics, outcome scores, response and remission rates, and exploratory session-frequency subgroups were compared. All analyzed variables were checked against complete medical records; no missing values were identified, and no imputation was performed.

RESULTS: The VR and control groups did not differ significantly in baseline depressive or anxiety scores. At discharge, adjunctive VR-based relaxation training was associated with lower depressive and anxiety symptom scores than usual care alone. The VR group also showed higher response rates for both depressive and anxiety symptoms and a higher anxiety remission rate, whereas depression remission was similar. Exploratory session-frequency analyses suggested that anxiety improvement may be more consistently associated with VR exposure than depression remission; however, the pattern was not strictly linear and should be interpreted cautiously because treatment frequency was linked to hospitalization duration and routine care factors.

CONCLUSIONS: This study is innovative in evaluating structured VR-based relaxation training as an adjunct to routine inpatient depression care and in providing preliminary observations on session-frequency patterns in a real-world Chinese psychiatric setting. Unlike many previous VR studies conducted in noninpatient, nonclinical, or short-term experimental contexts, this study reflects everyday clinical practice among hospitalized patients with depressive disorders. The findings contribute practical evidence for integrating immersive relaxation into comprehensive inpatient care, particularly when additional anxiety relief is desired. Because the study was retrospective and nonrandomized, the findings indicate associations rather than causal effects and should be confirmed in prospective randomized controlled trials.

PMID:42398063 | DOI:10.2196/75251

JMIR Res Protoc. 2026 Jul 3;15:e85437. doi: 10.2196/85437.

ABSTRACT

BACKGROUND: Clinical triage requires integrating multiple information sources to identify patients at risk of deterioration. Tools capturing global health assessments beyond disease-specific scores are being developed using either bottom-up aggregation of simple indicators or top-down machine learning from large datasets. Their alignment with expert clinical judgment remains poorly characterized.

OBJECTIVE: This study evaluates 2 latent health measurement approaches: Frailty Index-laboratory, a transparent bottom-up tool aggregating laboratory abnormalities via deficit accumulation theory, and ETHOS-ARES (Enhanced Transformer for Health Outcome Simulation-Adaptive Risk Estimation System), a transformer-based foundation model generating multidimensional patient representations from electronic health records. We assess whether each tool’s severity rankings align with clinical consensus and whether they offer utility in triage decisions.

METHODS: In this 3-phase mixed methods study, at least 30 clinicians across hospital specialties reviewed 20 emergency department presentations derived from Medical Information Mart for Intensive Care IV-Emergency Department. Phase 1 compared unaided clinician severity and urgency judgments against model outputs using Spearman rank correlation, with a Turing-inspired indistinguishability test assessing whether model rankings fell within the distribution of clinician assessments. Phase 2 allocated clinicians to receive Frailty Index-laboratory or ETHOS-ARES outputs, measuring anchoring effects via within-person pre-post comparisons and exploring clinical utility through semistructured interviews analyzed using the Framework Method.

RESULTS: Ethics approval was granted in June 2025 (KCL Research Ethics Office; MRSP-24/25-48707). Recruitment began in October 2025 (32 clinicians recruited as of manuscript submission), with data collection expected to be completed in January 2026 and analysis planned for March or April 2026.

CONCLUSIONS: This study will quantify model-clinician agreement, measure anchoring effects, and generate qualitative insights on utility, trust, and adoption. The findings will inform the implementation of latent health measurement tools in clinical practice and provide a framework for the early-stage evaluation of artificial intelligence-based clinical decision support systems.

PMID:42398056 | DOI:10.2196/85437

JMIR Form Res. 2026 Jul 3;10:e92967. doi: 10.2196/92967.

ABSTRACT

BACKGROUND: Informal caregivers of people living with dementia often experience high rates of caregiver burnout while providing care. Although there are many websites and mobile apps available to help caregivers, many do not use digital tools. The Olera platform was developed to be an easily adoptable web-based support tool, connecting caregivers with long-term services and supports, financial assistance, and educational resources. The platform was developed based on the Build-Measure-Learn framework with input from caregiver needs assessments and usability studies.

OBJECTIVE: This study aims to evaluate the quantitative and qualitative feedback of informal caregivers of people living with dementia on the second iteration of the Olera platform. The primary objective was to assess caregivers’ acceptance of this caregiving platform. The secondary objective was to use qualitative methods to explore (1) the study cohort’s challenges in daily caregiving to determine and compare them with prior literature, (2) their experience when using the Olera platform, and (3) their attitudes toward integrating artificial intelligence in caregiver services for future studies and platform development.

METHODS: Caregivers were recruited through various sources and screened for eligibility through an initial survey. Participants used the platform for 4 weeks and completed a survey with an adapted Technology Acceptance Survey (TAS) and qualitative open-ended questions at the end of the testing period. TAS responses were summarized with descriptive statistics, while ANOVAs, t tests, and linear regressions were used to compare the differences in the overall TAS scores by caregiver characteristics. Qualitative feedback data on the platform’s usefulness were analyzed via a thematic analysis framework approach.

RESULTS: A total of 65 caregivers in the United States completed the study, with a mean age of 59.9 (SD 9.8) years. The majority were female (61/65, 95.3%), non-Hispanic or Latino White (45/65, 69.2%), and the adult child of their care recipient (42/65, 64.6%). Evaluation of the Olera platform showed a high acceptance rate, with each TAS item scoring above 5.0 and an overall TAS score of 5.83 (SD 0.85) out of 7. Higher platform use frequency was associated with higher TAS ratings in technology acceptance (F3,61=7.88, P<.001). Thematic analyses elicited the caregiving challenges, evaluation of the Olera platform, and feedback on artificial intelligence-assisted support.

CONCLUSIONS: The Olera platform is an example of a beneficial web-based tool, though key features were requested to be included in the next iteration. Additionally, data supported prior findings regarding informal caregiver challenges and the insufficiency of conventional support mechanisms, indicating a need for more innovative digital solutions. Future research and development efforts using the Build-Measure-Learn approach are necessary to further iterate the platform’s key features, enhance the tool, involve more informal caregivers in its improvements, and serve as a model for customizable, person-centered online care support.

PMID:42398038 | DOI:10.2196/92967