Category: Statistics

JAMA Otolaryngol Head Neck Surg. 2026 Jun 25. doi: 10.1001/jamaoto.2026.1584. Online ahead of print.

ABSTRACT

IMPORTANCE: Quality of life (QOL) is considered the second most important outcome after survival in cancer care. In head and neck reconstruction, QOL has long been assumed to stabilize at 1 year, an assumption that guides clinical follow-up and trial design.

OBJECTIVE: To evaluate QOL beyond 1 year after head and neck reconstruction.

DESIGN, SETTING, AND PARTICIPANTS: This prospective cohort study of 315 patients with head and neck disease was conducted from 2015 through 2023 at a high-volume tertiary center in Taiwan. Data were analyzed March to August 2025.

EXPOSURE: Free flap reconstruction.

MAIN OUTCOMES AND MEASURES: The primary outcome was the physical domain of the University of Wisconsin QOL questionnaire. The primary end point was QOL time to deterioration (TTD), which accounts for reversibility and patient response shift, and to identify modifiable risk factors for deterioration, defined in TTD as a decline of 5 or more points without subsequent recovery of 5 or more points. For Cox proportional hazards models, statistical analysis included hazard ratios (HRs) with 95% CIs. The secondary end point was a composite of TTD or death.

RESULTS: Among 315 patients (mean [SD] age, 53.7 [11.8] years; 283 [89.8%] male; median follow-up, 1155 [95% CI, 1056 to 1254] days), baseline Cox models identified Charlson Comorbidity Index as associated with QOL deterioration (HR, 1.46; 95% CI, 1.22 to 1.74). In 12-month landmark models (N = 272), Charlson Comorbidity Index (HR, 1.70; 95% CI, 1.43 to 2.06), chemotherapy (HR, 1.60; 95% CI, 1.03 to 2.48), and complications (HR 2.01; 1.21 to 3.34) were associated with QOL deterioration. The composite end point showed similar results. QOL remained dynamic beyond 1 year, with 115 of 192 patients (59.9%) having clinically meaningful score changes between years 1 and 2 (58 of 192 [30.2%] improved, 57 of 192 [29.7%] deteriorated) despite stable cohort mean scores. Findings were consistent in analyses restricted to patients with malignant disease (n = 246). Exploratory baseline and 12-month risk scores demonstrated the feasibility of predicting dynamic QOL changes beyond 1 year.

CONCLUSIONS AND RELEVANCE: Results of this cohort study question the assumption that QOL stabilizes at 1 year after head and neck reconstruction. More than half of patients continued to experience clinically meaningful changes, with complications at 1 year representing the strongest modifiable risk factor for deterioration. Prognostic QOL risk scores provide an approach for targeting survivorship interventions to patients at highest risk for deterioration, shifting the focus from survival alone to preservation of QOL.

PMID:42348233 | DOI:10.1001/jamaoto.2026.1584

Environ Toxicol Chem. 2026 Jun 25:vgag174. doi: 10.1093/etojnl/vgag174. Online ahead of print.

ABSTRACT

Plastic pollution is one of the most persistent threats to aquatic ecosystems, yet studies in low-disturbed mountain aquatic environments remain scarce. This study examined the presence of macro- and microplastics in three rivers in the Montesinho Natural Park and adjacent areas, Portugal. It investigated how intrapopulational ecological traits of the signal crayfish (Pacifastacus leniusculus), a non-native species widely distributed across Europe, may influence contaminant accumulation. Sampling was conducted at five sites along an invasion gradient (front-core), where macroplastics along the margins and signal crayfish were collected, followed by laboratory analyses for the morphological and polymeric characterization of the plastics. Chemical identification was performed using Fourier-transform infrared spectroscopy with attenuated total reflectance (FTIR-ATR) and Raman spectroscopy. Behavioural assays of boldness and aggressiveness were carried out on 100 captured signal crayfish individuals. Macroplastics were detected in all sampling sites. Microplastic abundance was higher at the invasion front, and the digestive tract contained significantly more particles than the gills, suggesting that the digestive tract is the primary route of exposure. No differences were detected between sex or individual size. Fibers were the dominant form, mainly in blue and black colors, and polymers such as polyethylene terephthalate (PET), polyethylene (PE), and polypropylene (PP) prevailed. Although personality traits differed between the invasion front and the core, with generally bolder and more aggressive individuals at the front, behavioural responses also showed sex-related patterns, with females tending to leave the shelter faster and males showing higher aggressiveness. However, no statistically significant correlations were found between animal personality and microplastic accumulation. Overall, our results indicate that plastic contamination depends on multiple factors arising from interactions between local environmental factors, including hydromorphological processes, and intrapopulational ecological traits (i.e., diet). This study highlights the importance of integrating behavioural analyses to better understand differential exposure to contaminants and their potential environmental implications for non-native species and possible legacy for native communities.

PMID:42348218 | DOI:10.1093/etojnl/vgag174

JAMA Netw Open. 2026 Jun 1;9(6):e2611885. doi: 10.1001/jamanetworkopen.2026.11885.

ABSTRACT

IMPORTANCE: Hospital quality reporting remains a manual, costly process with critical limitations as a mechanism to improve care outcomes.

OBJECTIVE: To assess whether near-real-time quality measurement, enabled by large language models (LLMs), can improve quality performance as measured by the Centers for Medicare & Medicaid Services (CMS) Severe Sepsis and Septic Shock Management Bundle (SEP-1) quality metric.

DESIGN, SETTING, AND PARTICIPANTS: This single-blind, unstratified, cluster randomized trial was conducted between December 13, 2024, and July 8, 2025, at 2 academic emergency departments (EDs) within the University of California, San Diego (UCSD) health system. Participants included all 66 attending physicians who practiced in the UCSD EDs and worked more than 3 shifts per month prior to study initiation.

INTERVENTION: Participants were randomized to receive targeted feedback from LLM-determined compliance with SEP-1 at the time of patient discharge or standard process.

MAIN OUTCOMES AND MEASURES: The primary outcome was overall compliance with SEP-1. Secondary outcomes included expert agreement with the LLM SEP-1 determination, 30-day mortality, and intensive care unit admissions of patients with severe sepsis and/or septic shock in the ED. Effect sizes were estimated from a mixed-effects logistic regression model with the intervention group as a fixed effect and a random intercept for physician.

RESULTS: The study population included 66 physicians who treated 301 patients (121 in the control group and 180 in the intervention group; median age, 64.3 [IQR, 51.1-75.7] years; 171 [56.8%] male; 52 [17.3%] with chronic kidney disease; 52 [17.3%] with chronic heart failure) who met CMS inclusion criteria for SEP-1. Physicians in the control group had a SEP-1 compliance rate of 70.1%, while those in the intervention group had a rate of 82.9%. Assignment to the intervention group resulted in a 13.0% absolute improvement in SEP-1 compliance (95% CI, 2.5%-23.4%; odds ratio, 2.10 [95% CI, 1.15-3.81]; P = .02) in the mixed-effects model. The largest difference between the intervention group and control group was in noncompletion of the 30-mL/kg fluid bolus component (3 of 180 [1.7%] vs 16 of 121 [13.2%]), a documentation-sensitive component of the quality measure. Agreement between LLM determination and expert review was 92%. No significant differences existed in intensive care unit admissions or 30-day mortality.

CONCLUSIONS AND RELEVANCE: In this cluster randomized trial of artificial intelligence (AI)-enabled medical record abstraction for sepsis care, rapid assessment of SEP-1 performance and targeted feedback improved overall compliance with the measure. AI-driven quality clinical integration may address limitations in existing hospital quality reporting and better support a learning health system.

TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT07581340.

PMID:42348212 | DOI:10.1001/jamanetworkopen.2026.11885

JAMA Netw Open. 2026 Jun 1;9(6):e2620122. doi: 10.1001/jamanetworkopen.2026.20122.

ABSTRACT

IMPORTANCE: In low- and middle-income countries (LMICs), limited access to adequate prosthetic care hinders the psycho-socio-motor development and educational progress of children and adolescents with upper limb differences. The suitability of current pediatric prosthetic solutions and the needs and expectations of children and adolescents with upper limb differences regarding upper limb prostheses (ULPs) remain understudied in LMICs.

OBJECTIVES: To examine and characterize the needs, expectations, and perceptions of Nigerian children and adolescents with upper limb differences regarding ULPs, assessing contextualized specifications for prosthetic development.

DESIGN, SETTING, AND PARTICIPANTS: This qualitative study was conducted from July 20 to July 23, 2024, in Lagos, Nigeria, among 25 children and adolescents with upper limb differences purposively selected from The IREDE Foundation prosthetic care program; recipients were aged 5 through 20 years who possessed at least 1 ULP. This study involved semistructured interviews and focus groups of Nigerian children and adolescents with upper limb differences. Transcripts were analyzed using thematic analysis between August 2024 and May 2025.

MAIN OUTCOMES AND MEASURES: The needs and perceptions of children and adolescents with upper limb differences regarding ULPs.

RESULTS: A total of 25 children and adolescents with upper limb differences (mean [SD] age, 13.5 [4.2] years; 15 male [60%]) enrolled in the study; 14 were interviewed, and 11 engaged in focus groups. The predominant cause of upper limb differences was traumatic amputations (16 [64%]), and the predominant level of upper limb differences was transhumeral (16 [64%]). Seven themes were identified from the interviews and focus groups. First, the children and adolescents with upper limb differences described the technical specifications of an ideal ULP by (1) highlighting the functionalities and task performance it should enable; (2) expressing their need for an active ULP and the characteristics of effective terminal devices; (3) specifying user-defined requirements for quality of prostheses components; (4) describing factors contributing to comfortable wear and use; and (5) explaining the necessity for anthropomorphism (shape and color) of ULP designs. Second, the psychosocial consequences of the conditions of the children and adolescents with upper limb differences and ULP use emerged: adverse repercussions (6) on self-concept and (7) in interactions with their social network, which were major factors in ULP acceptance. Overall, children and adolescents with upper limb differences expressed the need for an active, anthropomorphic, sturdy ULP, enabling them to actively engage with their peers.

CONCLUSIONS AND RELEVANCE: In this qualitative study, children and adolescents with upper limb differences expressed perceptions regarding their current ULP and described the requirements of prosthetic devices meeting the psychosocial and occupational needs within their socialcultural environment. Future studies could incorporate these findings into the development of environment-specific pediatric ULPs.

PMID:42348211 | DOI:10.1001/jamanetworkopen.2026.20122

JAMA Netw Open. 2026 Jun 1;9(6):e2620128. doi: 10.1001/jamanetworkopen.2026.20128.

ABSTRACT

IMPORTANCE: Females with atrial fibrillation (AF) experience a higher risk of stroke, myocardial infarction, and mortality than males with AF. Theories suggest that sex-based differences in hormonal, structural, and electrophysiologic factors are associated with this imbalance; we hypothesized that sex-based differences in health care access and utilization (HCAU) are also underlying factors.

OBJECTIVE: To determine whether sex-based disparities in HCAU barriers exist among individuals with AF.

DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study used data on patients with AF in the All of Us Research Program Registered Tier dataset (version 8), which contains integrated data from the electronic health record and various health surveys between August 8, 2016, and October 1, 2023. Inclusion criteria were age 18 years or older, a SNOMED (Systematized Nomenclature of Medicine) diagnosis of AF, and completion of the Health Care Access and Utilization Survey. Exclusion criteria included lack of binary sex information. Data were extracted and analyzed between November 2025 and April 2026.

MAIN OUTCOMES AND MEASURES: Association between sex at birth and participant responses to 20 HCAU outcomes. Multivariable logistic regression and marginal standardization were used to calculate unadjusted and adjusted odds ratios, adjusted predicted probabilities (APPs), and adjusted risk differences (ARDs). Multiplicity was addressed using the Holm-Bonferroni method.

RESULTS: The 12 428 eligible participants had a median (IQR) age of 70 (63-75) years and included 6877 males (55.3%). Compared with males with AF, females with AF had significantly higher APPs of reporting HCAU barriers to 14 of 20 outcomes after adjusting for baseline differences in sociodemographic and clinical characteristics. The largest differences were observed in cost-related medication access and adherence behaviors and nervousness about seeing a health care practitioner. Females compared with males were more likely to report asking for a lower-cost medication (APP, 25.12% [95% CI, 23.92%-26.32%] vs 20.84% [95% CI, 19.82%-21.86%]; ARD, 4.28 [95% CI, 2.65-5.90] percentage points), being unable to afford prescription medications (APP, 12.77% [95% CI, 11.93%-13.61%] vs 9.20% [95% CI, 8.47%-9.93%]; ARD, 3.57 [95% CI, 2.42-4.72] percentage points), delaying prescription fills (APP, 11.20% [95% CI, 10.38%-12.01%] vs 7.81% [95% CI, 7.12%-8.50%]; ARD, 3.39 [95% CI, 2.29-4.48] percentage points), and being nervous about seeing a health care practitioner (APP, 9.35% [95% CI, 8.57%-10.14%] vs 6.18% [95% CI, 5.56%-6.80%]; ARD, 3.17 [95% CI, 2.14-4.21] percentage points).

CONCLUSIONS AND RELEVANCE: In this cross-sectional study, females with AF reported a greater burden of HCAU barriers than males with AF. This finding may explain some of the observed differences in AF outcomes between sexes.

PMID:42348210 | DOI:10.1001/jamanetworkopen.2026.20128

JAMA Netw Open. 2026 Jun 1;9(6):e2620192. doi: 10.1001/jamanetworkopen.2026.20192.

ABSTRACT

IMPORTANCE: Individuals with chronic kidney disease (CKD) are disproportionately admitted to the intensive care unit (ICU); however, the association between CKD severity and outcomes after ICU admission remains uncertain.

OBJECTIVE: To evaluate the association between CKD severity and health outcomes after ICU admission.

DESIGN, SETTING, AND PARTICIPANTS: This population-based cohort study was conducted from November 1, 2008, to February 28, 2021. Participants included 531 090 consecutive adult (≥18 years) residents of Ontario, Canada, admitted to an ICU during the study period who had a baseline outpatient serum creatinine measurement within 7 to 365 days prior to admission. Statistical analyses were conducted from July 23, 2025, to April 16, 2026.

EXPOSURE: CKD severity was classified according to the baseline outpatient estimated glomerular filtration rate (eGFR) Kidney Disease Improving Global Outcomes criteria.

MAIN OUTCOMES AND MEASURES: Mortality (ICU, hospital, and 90-day mortality) and kidney replacement therapy (KRT) requirement in the ICU and dependence at 90 days.

RESULTS: The study included 531 090 adults (mean [SD] age, 67 [15] years; 57% men) admitted to the ICU. One in 4 individuals had preexisting CKD: stage 3a CKD, eGFR 45 to 59 mL/min/1.73 m2 (12% of adults); stage 3b CKD, eGFR 30 to 44 mL/min/1.73 m2 (7% of adults); stage 4 CKD, eGFR 15 to 29 mL/min/1.73 m2 (3% of adults); non-dialysis-dependent stage 5 CKD, eGFR less than 15 mL/min/1.73 m2 (1% of adults); and undergoing maintenance dialysis (2% of adults). Compared with individuals without CKD, the severity of the disease among individuals with CKD was progressively associated with increased mortality risk up to non-dialysis-dependent stage 5 CKD. However, the risk of mortality was lower for individuals receiving maintenance dialysis (odds ratio [OR], 1.92 [95% CI, 1.82-2.04]) compared with those with non-dialysis-dependent stage 5 CKD (OR, 2.32 [95% CI, 2.14-2.52]). Risk for KRT initiation in the ICU increased with CKD severity relative to individuals without CKD: stage 3a (adjusted OR [AOR], 1.79 [95% CI, 1.68-1.90]), stage 3b (AOR, 3.02 [95% CI, 2.83-3.22]), stage 4 (AOR, 6.71 [95% CI, 6.23-7.22]), and non-dialysis-dependent stage 5 (AOR, 32.00 [95% CI, 29.07-35.22]). Among those who initiated KRT in the ICU and survived to 90 days, KRT dependence at day 90 increased progressively by CKD stage: no CKD, 7.2%; stage 3a, 14.2%; stage 3b, 22.5%; stage 4, 50.3%; and previously non-dialysis-dependent stage 5, 83.8%.

CONCLUSIONS AND RELEVANCE: In this cohort study of consecutive adults admitted to the ICU, the presence and severity of CKD were associated with adverse health outcomes. These findings can inform risk prognostication, discussions about goals of care, resource allocation, and health policy initiatives for this large portion of the ICU population.

PMID:42348209 | DOI:10.1001/jamanetworkopen.2026.20192

Ir Med J. 2026 Jun 18;119(6):108.

ABSTRACT

AIMS: Mayo University Hospital performs approximately 350 joint arthroplasty surgeries per annum. We revised our analgesia protocol in 2024 based on best current practice.

METHODS: We conducted this evaluation from January to July 2025. All patients presenting for joint arthroplasty surgeries were invited to be included.

RESULTS: Our evaluation included 147 patients; 94 patients had a total hip arthroplasty and 53 had a total knee arthroplasty. The average age was 69 years, and 142 (96.5%) of patients were living at home independently before surgery. 53 (36%) were on prescribed analgesics pre-operatively. The average pain score on day 1 (day after surgery) was 4.8 for the hip arthroplasty patients and 5.5 for the knee arthroplasty patients. The total oral morphine equivalent requirements for the first 2 days were 48 mgs for the hip surgery patients and 65 mgs for the knee surgery patients. The median length of stay for all patients was 4 days. On follow up at 6 weeks, 135 (91%) of patients were mobilising independently. Overall satisfaction of the patient’s experience (0-10) was 8.7 for the knee arthroplasty patients and 8.8 for the hip arthroplasty patients.

DISCUSSION: Overall, we were satisfied with our analgesic protocol, but we want to improve the day 1 and 2 pain scores particularly in the knee arthroplasty patients. We are discussing the introduction of adductor canal blocks pre-operatively.

PMID:42348181

Infect Dis Ther. 2026 Jun 25. doi: 10.1007/s40121-026-01384-7. Online ahead of print.

ABSTRACT

INTRODUCTION: Data on the influenza burden in Germany during and after the global COVID-19 pandemic are limited. This study presents nationwide trends in the clinical and economic inpatient burden of influenza and influenza-like illness (ILI) in the German population from 2019 to 2025.

METHODS: We conducted a descriptive, retrospective analysis of nationwide hospital data from the German Institute for Hospital Reimbursement covering six consecutive influenza seasons (2019-2020 to 2024-2025). Influenza/ILI hospitalizations were identified using the International Classification of Diseases version 10 (ICD-10) codes J09-J11 recorded as primary diagnosis. Outcomes included hospitalization counts, incidence rates, mean length of stay, ICU admissions, in-hospital mortality, and estimated costs, and were reported for three age groups (0-17 years, 18-59 years, ≥ 60 years). Regional variation across federal states was assessed using directly age-standardized rates.

RESULTS: We identified 240,646 influenza/ILI hospitalizations, with the highest burden observed in the 2024-2025 season (87,745 cases; incidence: 105.0/100,000 population). Less than 5000 cases were observed in both the 2020-2021 and 2021-2022 seasons. Across all seasons, adults aged ≥ 60 years accounted for 48% of hospitalizations and 92% of 10,054 in-hospital deaths. In this age group, in-hospital mortality ranged between 5.8% and 12.3% per season. Mean hospitalization costs per case increased during the study period and were highest in older adults, reaching €5430 in 2023-2024 and €5421 in 2024-2025. Total inpatient costs of influenza/ILI were highest in 2024-2025 and estimated at €390 million. Regional hospitalization rates varied considerably, but patterns were inconsistent across seasons.

CONCLUSIONS: Influenza/ILI causes a substantial and re-emergent inpatient burden in Germany, disproportionately affecting older adults. These findings highlight the need for sustained prevention efforts to reduce the burden of influenza/ILI in Germany. Further research is needed to understand the substantial regional disparities between federal states.

PMID:42348163 | DOI:10.1007/s40121-026-01384-7

J Clin Hypertens (Greenwich). 2026 Jun;28(6):e70321. doi: 10.1111/jch.70321.

ABSTRACT

Carotid-femoral pulse wave velocity (cfPWV) and brachial-ankle pulse wave velocity (baPWV) are widely used indicators of arterial stiffness, with cfPWV considered the gold standard and baPWV increasingly applied in Asian populations. In this community-based cohort from Beijing, we compared the associations of cfPWV and baPWV with the risk of new-onset cardiovascular events. A total of 5723 residents from the Shougang community with available cfPWV and baPWV measurements from the 2018 follow-up survey were included. CfPWV was measured using Pulsepen and baPWV using the Omron BP-203RPE III device. Cardiovascular events, defined as a composite outcome of cardiovascular death, first-ever myocardial infarction, or stroke, were identified from national and municipal registries through December 31, 2021. Over a median follow-up of 3.15 years, 173 cardiovascular events occurred. Both cfPWV and baPWV were associated with incident cardiovascular events in Kaplan-Meier analyses. However, in multivariable Cox regression models adjusting for traditional cardiovascular risk factors, cfPWV showed a nonsignificant trend (p = 0.072), while baPWV remained significantly associated with new-onset events (p < 0.001). These findings indicate that in this community-based population, baPWV, but not cfPWV, demonstrates a robust association with cardiovascular risk, suggesting that baPWV may serve as a more practical and effective tool for routine cardiovascular risk assessment in Asian populations.

PMID:42348156 | DOI:10.1111/jch.70321

3D Print Med. 2026 Jun 25. doi: 10.1186/s41205-026-00329-7. Online ahead of print.

ABSTRACT

BACKGROUND: The Latarjet procedure is effective for treating recurrent anterior shoulder instability, but graft-related complications may occur. Accurate preoperative planning is essential to minimize these complications. Three-dimensional (3D) printed models may support surgical planning; however, their role in Latarjet surgery remains unclear. This study aimed to evaluate whether coracoid dimensions measured on 3D-printed models differ from intraoperative measurements and whether their use influences surgical decision-making.

METHODS: In this cross-sectional study, 25 patients underwent computed tomography based 3D printing of the scapula. Coracoid length, width, and thickness were measured on the 3D-printed models and compared with intraoperative pre- and post-osteotomy measurements using precision calipers. Surgeons also subjectively rated the usefulness of the 3D models for surgical planning.

RESULTS: No significant differences were observed in coracoid thickness among the three measurement time points (p = 0.6956). Significant differences were found for coracoid length (p = 0.0005) and width (p = 0.02) between the 3D model and pre-osteotomy measurements, while no differences were observed between pre- and post-osteotomy measurements. The models were rated as “very helpful” in 28% of cases, “somewhat helpful” in 52%, and “not helpful” in 20%. In three cases, preoperative planning with the 3D model resulted in a change in fixation strategy.

CONCLUSION: Three-dimensional printed coracoid models provide reliable estimation of coracoid thickness and may assist in preoperative planning in selected Latarjet procedures, particularly when graft adequacy or fixation strategy is uncertain. Although statistically significant differences in length and width were observed, the models were considered helpful in most cases.

LEVEL OF EVIDENCE: IV.

PMID:42348155 | DOI:10.1186/s41205-026-00329-7