Category: Statistics

JMIR Res Protoc. 2026 Apr 21;15:e86384. doi: 10.2196/86384.

ABSTRACT

BACKGROUND: As a prevalent side effect, chemotherapy-induced nausea and vomiting (CINV) imposes a burden on the daily lives of patients with breast cancer. Multiple clinical trials have suggested the validity of acupuncture in alleviating CINV; however, the optimal acupuncture modality remains unclear.

OBJECTIVE: This protocol describes a systematic review and network meta-analysis to investigate the efficacy and safety of distinct acupuncture interventions for treating CINV in patients with breast cancer.

METHODS: Eight databases (PubMed, Embase, Web of Science, the Cochrane Library, China National Knowledge Infrastructure, VIP Database, Wanfang Database, and the Chinese Biomedical Literature Database) will be searched for eligible studies from their respective inception to July 31, 2025. The language of published studies is limited to English and Chinese. Primary outcomes are CINV intensity and clinical effectiveness rates. Secondary outcomes include recurrence rates, safety outcomes, and quality of life. Risk of bias will be assessed using the Cochrane risk of bias tool. Pairwise meta-analysis will be conducted in Stata using random-effects models with Hartung-Knapp-Sidik-Jonkman CIs. Network meta-analysis will be conducted using Bayesian Markov chain Monte Carlo methods in R software. Convergence will be assessed using Gelman-Rubin statistics and trace plots. Heterogeneity will be summarized using τ2 and τ, along with prediction intervals, when applicable. Consistency between direct and indirect evidence will be evaluated using the node-splitting method and design-by-treatment interaction test. Small-study effects will be assessed via comparison-adjusted funnel plots and the Egger test in Stata. Where feasible, subgroup analyses and meta-regression analyses will be performed. The certainty of evidence will be evaluated using the Grading of Recommendations Assessment, Development, and Evaluation framework.

RESULTS: A preliminary scoping search was completed in August 2025, and this protocol was finalized in October 2025. The comprehensive literature search and study selection are expected to be completed by June 2026, followed by data extraction by August 2026. Data synthesis and final manuscript preparation are scheduled to be completed by December 2026.

CONCLUSIONS: This analysis will expand the range of evidence-based acupuncture options available to clinicians for treating CINV in patients with breast cancer.

PMID:42013419 | DOI:10.2196/86384

JMIR Hum Factors. 2026 Apr 21;13:e83427. doi: 10.2196/83427.

ABSTRACT

BACKGROUND: High-quality professional development can help teachers build the skills and confidence needed to implement evidence-based practices, such as classroom physical activity breaks. While in-person training is often preferred, virtual asynchronous training offers a flexible alternative for teachers. However, its effectiveness may be limited by design and usability challenges.

OBJECTIVE: The aim of this study was to conduct a usability assessment of the Interrupting Prolonged Sitting with Activity (InPACT) virtual teacher training modules, using a human-centered design (HCD) approach to align the training with end-user preferences and needs.

METHODS: The InPACT professional development program includes nine modules delivered through an online platform (Qualtrics XM). A usability assessment was conducted using (1) structured online surveys with elementary school teachers who had completed the modules, (2) a heuristic evaluation based on the Jakob Nielsen 10 usability heuristics, and (3) a competitive analysis of three learning management systems (Moodle, Teachable, and Thinkific) to identify platform strengths, limitations, and insights. Findings and recommendations were compiled to inform module improvements.

RESULTS: Eleven teachers completed the survey. They reported that the modules were easy to use, the content was informative and relevant, and they valued the interactive and practical components. Areas for improvement included enhancing content engagement and increasing technical flexibility. The heuristic evaluation identified 14 usability issues across nine of the Nielsen heuristics (eg, navigation difficulties and text-heavy pages). The competitive analysis highlighted features that enhance user experience, such as progress tracking, estimated completion times, interactive elements, and feedback on quiz answers.

CONCLUSIONS: Usability assessments grounded in an HCD approach can enhance virtual training for educators, improving the uptake and implementation of evidence-based practices, such as classroom physical activity breaks. Five overarching recommendations emerged as follows: (1) removing video time constraints, (2) implementing accurate progress bars, (3) incorporating active learning or retention activities, (4) creating consistent and actionable end pages, and (5) ensuring consistency in titles and references to physical materials. Building on preliminary positive data from revised modules, future research should evaluate the impact of HCD revisions on teacher self-efficacy, training completion, and fidelity of program implementation.

PMID:42013411 | DOI:10.2196/83427

Neurology. 2026 May 12;106(9):e214937. doi: 10.1212/WNL.0000000000214937. Epub 2026 Apr 21.

ABSTRACT

BACKGROUND AND OBJECTIVES: Disability rating scales play a pivotal role in clinical trials, but there is a notable lack of guidance on how to analyze these scales. Using amyotrophic lateral sclerosis as a case study, our aim was to explore how disability rating scales have been analyzed in completed clinical trials and to assess how these different approaches influence both the risk of false-positive findings and the statistical power to detect true treatment effects.

METHODS: We searched PubMed and Embase to systematically identify randomized, placebo-controlled clinical trials using the revised ALS functional rating scale (ALSFRS-R) as primary end point, with ≥20 randomly assigned patients and ≥12-weeks of follow-up. Data were extracted on the statistical analysis approaches and strategies for handling missing data. Variability in statistical methods was mapped to the various research questions that the trials aimed to address. A simulation study assessed how each statistical method influenced validity (false-positive rate) and precision (statistical power), using the Ceftriaxone trial data set to model a realistic trial scenario.

RESULTS: Our analysis included 45 randomized clinical trials, comprising a total sample size of 7,338 patients, and identified 39 distinct statistical methods using a mixture of longitudinal and cross-sectional techniques. Most trials (55.6%) did not use all available (longitudinal) ALSFRS-R measurements, resulting in suboptimal utilization of patient data and reduced statistical precision. Applying the different statistical methods to the same trial data set resulted in large differences in the estimated treatment effect size, ranging from a negative 1.33 to a positive 2.33 SD difference. Among the methods used, 38.9% (95% CI 24.8%-55.1%) were at risk of increasing false-positive rates, potentially contributing to the erroneous advancement of ineffective treatments. Statistical power of valid strategies varied widely, ranging from 17.9% to 78.2%.

DISCUSSION: Our results demonstrate considerable variability in statistical methods, with the choice of method able to influence the estimated treatment effects, potentially resulting in misleading conclusions and uncertainty about treatment effects. This limits the interpretability and comparability of clinical trials and influences clinical decision-making and drug development. Establishing statistical consensus recommendations could improve the utility of disability scales in clinical trials and accelerate progress toward effective therapies for neurodegenerative diseases.

PMID:42013406 | DOI:10.1212/WNL.0000000000214937

JMIR Aging. 2026 Apr 21;9:e85626. doi: 10.2196/85626.

ABSTRACT

BACKGROUND: With the growing aging population, technology that supports independent living is increasingly important. Web search systems are well established, whereas generative artificial intelligence (Gen-AI; eg, ChatGPT) represents a newer, adaptive tool that could offer personalized information access. However, little is known about how older adults, particularly those with mild cognitive impairment (MCI) or mild dementia, perceive and engage with these systems.

OBJECTIVE: This study explored the use of and perspectives on web search and Gen-AI in older adults with and without cognitive impairment (including MCI and early-stage dementia).

METHODS: A UK-wide mixed methods study was conducted with older adults, including those with MCI or mild dementia. An online survey captured technology use, Likert-scale ratings of web search and Gen-AI, and reasons for nonuse. Follow-up focus groups provided in-depth qualitative perspectives. Quantitative data were analyzed using descriptive and comparative statistics, while qualitative data were thematically analyzed.

RESULTS: Survey findings showed higher use of web search (275/280, 98.2%) compared to Gen-AI (40/286, 14%) within these groups. Web search was rated positively across participants, although challenges were raised regarding the phrasing of queries and commercialization. Gen-AI use was less common, but more than half of nonusers expressed willingness to adopt it in the future. Combined with focus group responses, themes exploring keyword searching, mistrust, lack of knowledge, and willingness to learn were established. Participants also suggested potential applications of Gen-AI, such as supporting independent living through monitoring and simplifying complex searches.

CONCLUSIONS: Web search remains the primary method, and participants highlighted both advantages and frustrations with current systems. Gen-AI was underused but seen as promising, with its adoption mainly limited by mistrust and knowledge gaps. Our findings indicate that structured training, early introduction, and user-centered design could encourage adoption, enhance accessibility, and support independent living among older adults with and without MCI.

PMID:42013397 | DOI:10.2196/85626

Int J Soc Determinants Health Health Serv. 2026 Apr 21:27551938261442743. doi: 10.1177/27551938261442743. Online ahead of print.

ABSTRACT

The global refugee crisis has exacerbated health disparities, particularly among middle-aged and older refugees, yet limited research exists on this vulnerable group, especially in low-income countries. This study investigates the predictors of health accessibility among middle-aged and older Afghan refugees in Pakistan in light of the social determinants of health, operationalized across four dimensions: health spending, health provider facilities, health information, and health communication. Using microdata from the 2022 Health Access and Utilization Survey (n = 423) at the household level, the study employed descriptive statistics, chi-square test, and logistic regression to examine the association between sociodemographic factors and health accessibility. The findings revealed discrepancies in gender distribution, literacy levels, and language proficiency. Education was found to be a significant predictor of health providers and health information, while reading ability was negatively associated with health providers and communication, suggesting that basic literacy may not necessarily translate into functional health literacy. The findings underscore the need for inclusive and targeted health policies that extend beyond service provision and address both structural and communication barriers faced by aging refugees. Policy makers and humanitarian organizations should prioritize context-specific, culturally sensitive interventions to promote healthy aging outcomes among vulnerable refugees in Pakistan.

PMID:42012240 | DOI:10.1177/27551938261442743

Geospat Health. 2026 Feb 2;21(1). doi: 10.4081/gh.2026.1426. Epub 2026 Apr 21.

ABSTRACT

This study assessed spatial accessibility to fixed mammography centres across Oklahoma State, USA using the Two-Step Floating Catchment Area (2SFCA) and the Enhanced Two-Step Floating Catchment Area (E2SFCA) methods to identify areas with limited or no access. For this analysis, we used data from the mammography facilities database of the US Food and Drug Administration verified by direct contact with the facility and the U.S. Census block group population and demographics for women aged 40 years and older. Analyses were stratified by urban areas; large rural areas; and small rural areas. Accessibility scores were calculated using the 2SFCA method with 30-minute drive times and the E2SFCA method with drive times of 10, 20 and 30 minutes weighted by distance decay. Block groups were categorized into quartiles based on accessibility scores. Among 940,994 eligible women, 10% lived in areas with no access. Small rural regions faced the greatest barriers. Spatial disparities were linked to racial and socioeconomic differences: non-Hispanic American Indian/Alaska Native and non-Hispanic White populations were more likely to reside in noaccess zones, while Black and Hispanic populations clustered in high-access urban areas. Spatial analysis reveals significant rural disparities in mammography access. Mobile machines should prioritize underserved rural regions to improve equity.

PMID:42012222 | DOI:10.4081/gh.2026.1426

Int J Ment Health Nurs. 2026 Apr;35(2):e70262. doi: 10.1111/inm.70262.

ABSTRACT

Moral courage is a critical attribute for psychiatric and mental health nurses, who routinely navigate complex ethical dilemmas in mental health care settings. Despite its importance, limited research has explored moral courage and its relationship with ethical decision-making confidence among Registered Psychiatric Nurses. The purpose of this study was to examine the relationship between moral courage, ethical decision-making confidence, education level, and years of practice among Registered Psychiatric Nurses in western Canada. A cross-sectional multiple-methods design that adhered to the STROBE Checklist EQUATOR Network was used, involving 80 participants recruited within western Canada. Data was collected using the Nurses’ Moral Courage Scale that utilised open- and close-ended questions as well as the Ethical Decision-Making Confidence scale. Statistical data was analysed using parametric and non-parametric tests to assess group differences. Narrative data was analysed using thematic analysis. The findings revealed a significant positive relationship between moral courage and ethical decision-making confidence. Ethical decision-making confidence scores were higher among nurses with graduate-level education compared to those with diplomas or baccalaureate degrees. However, no significant difference in moral courage scores was observed based on education level or years of practice, and no significant association was found between years of practice and moral courage. Qualitative findings revealed four major themes that included: (1) Advocating; (2) Patient Safety; (3) Reporting Co-Workers; and (4) Standing up to Co-Workers and Superiors. This study highlights the interconnectedness of moral courage and ethical decision-making among psychiatric nurses, while revealing that years of practice alone do not predict moral courage.

PMID:42012195 | DOI:10.1111/inm.70262

Clin Rehabil. 2026 Apr 21:2692155261432011. doi: 10.1177/02692155261432011. Online ahead of print.

ABSTRACT

DesignA cross-sectional study.SettingPatients with burn injuries often present with joint contracture caused by hypertrophic scars. To assess the patient’s degree of disability or outcome to rehabilitation treatment, various objective assessment tools are used, such as a standard goniometer, which is often used for measuring joint range of motion; however, measurements using a handheld goniometer may have a large margin of error depending on the therapist’s experience. Herein, the reliability and validity of a novel marker-based system were investigated for evaluating joint range of motion in patients with burn injuries.ParticipantsIn total, 48 participants with joint contractures in the shoulder, elbow, and wrist owing to hypertrophic scars after thermal injury were enrolled.InterventionUpper extremity joint range of motion was measured using a goniometer and optical motion capture system (Session 1), followed by remeasurement 2 days later (Session 2).Main measuresTwenty-two reflective markers were attached to the upper limbs, and motion analysis was measured using eight infrared cameras.ResultsNo statistical differences were detected between the range of motion values measured using the two methods. The measurements based on the optical motion capture system showed excellent intra-rater reliability.ConclusionsThe findings of this study highlight the value of the motion capture system as a tool to objectively evaluate the joint range of motion in patients with contractures caused by burns.This study was registered at ClinicalTrials.gov (Identifier: NCT05881876).

PMID:42012175 | DOI:10.1177/02692155261432011

Microbiol Spectr. 2026 Apr 21:e0359525. doi: 10.1128/spectrum.03595-25. Online ahead of print.

ABSTRACT

Murine typhus, caused by Rickettsia typhi, is a globally distributed flea-borne disease. Antimicrobial susceptibility data are largely based on reference strains, with little evaluation of variability across clinical isolates. The plaque assay, the gold standard for antibiotic susceptibility testing, requires up to 14 days to complete. Quantitative real-time PCR (qPCR) offers a rapid alternative for determining minimum inhibitory concentrations (MICs). Although qPCR-based susceptibility testing has been described, formal statistical assessment of agreement between methods remains limited. We estimated the MICs for azithromycin, doxycycline, and amoxicillin using qPCR and plaque assay on 24 R. typhi isolates (8 laboratory strains and 16 Lao clinical isolates) cultured in Vero cells. Heat-inactivated R. typhi (56°C, 30 min) served as a control. MIC was defined as the lowest concentration preventing plaque formation (plaque assay) or producing a Ct value greater than or equal to that of the heat-inactivated sample (qPCR). The mean MIC from three independent experiments was taken to represent each isolate. Agreement between methods was assessed using Bland-Altman analysis. Median qPCR MICs (MIC₅₀) of all isolates were 0.130 mg/L (IQR, 0.104-0.240 mg/L) for azithromycin, 0.130 mg/L (IQR, 0.065-0.224 mg/L) for doxycycline, and 256 mg/L (IQR, 234.7-341.3 mg/L) for amoxicillin. Corresponding plaque assay MICs₅₀ were 0.383 mg/L (IQR, 0.194-0.807 mg/L), 0.037 mg/L (IQR, 0.026-0.073 mg/L), and 170.7 mg/L (IQR, 112-256 mg/L), respectively. Bias was -0.3452 (-1.146, 0.4558) for azithromycin, 0.0969 (-0.2297, 0.4235) for doxycycline, and 85.33 (-187.3, 358) for amoxicillin. These findings demonstrate inter-isolate variability and quantitative agreement between methods.IMPORTANCEMurine typhus is a treatable febrile illness caused by Rickettsia typhi, transmitted to humans via fleas. The plaque assay, which detects bacterial-induced host cell death in the presence or absence of antibiotics, is the reference method for testing drug susceptibility. However, the method requires approximately 2 weeks to obtain results. Detection of bacterial nucleic acid provides an alternative laboratory approach that reduces the assay duration to approximately 1 week, thereby improving research efficiency and throughput when testing multiple isolates. Compared with plaque assays, quantitative real-time PCR allows downstream analysis following sample inactivation, reducing prolonged high-containment handling. In this study, we compared the antibiotic susceptibility of 24 R. typhi isolates using both methods. We tested antibiotics commonly used to treat R. typhi infection (doxycycline and azithromycin), along with amoxicillin as a negative control. Both showed comparable results for all antibiotics tested, further supporting nucleic acid detection as a reliable and faster alternative.

PMID:42012166 | DOI:10.1128/spectrum.03595-25

Telemed J E Health. 2026 Apr 21:15305627261444704. doi: 10.1177/15305627261444704. Online ahead of print.

ABSTRACT

BACKGROUND: Telemedicine (TM) is increasingly integrated into health care delivery; however, its safe and effective implementation depends on the competency of the nursing workforce. Although previous research has examined TM utilization among nurses, evidence regarding TM competency levels remains limited.

PURPOSE: To assess TM-related competencies across four domains: awareness, knowledge, attitudes, and skills among nurses in the United Arab Emirates, and identify factors associated with each domain.

METHODS: A cross-sectional survey was conducted among 434 nurses working in governmental health care facilities. TM competencies were measured using a structured online questionnaire incorporating demographic characteristics and the validated TM Awareness, Knowledge, Attitude, and Skills instrument. Descriptive statistics and multiple linear regression analyses were performed to evaluate competency levels and their predictors.

RESULTS: Nurses demonstrated high TM knowledge (81.44 ± 22.27) and positive attitudes (81.42 ± 10.27), with 77.0% and 92.4% of participants scoring high in these domains, respectively. Awareness (55.89 ± 26.17) and skills (57.11 ± 23.01) were more moderate, with only 28.6% and 24.4% of nurses scoring high in these domains, respectively. Interest in TM was a positive predictor of competency across all domains (p < 0.001). Postgraduate education and TM training were associated with higher awareness, while male gender, postgraduate qualification, and higher interest predicted improved skill scores. Regression models explained 8-16% of variance across competency domains.

CONCLUSIONS: Although nurses demonstrated strong knowledge and positive attitudes toward TM, gaps remain in awareness and practical skills. Competency-based, skill-focused TM training is needed to support safe and sustainable integration into nursing practice.

PMID:42012148 | DOI:10.1177/15305627261444704