Category: Statistics

J Cardiovasc Electrophysiol. 2026 Jul 8. doi: 10.1111/jce.70447. Online ahead of print.

ABSTRACT

INTRODUCTION: Atrial fibrosis is an adverse factor for arrhythmia recurrences and thromboembolic events in atrial fibrillation (AF). Cardiac magnetic resonance imaging (CMRi) has emerged as a noninvasive tool for its assessment, though evidence remains conflicting.

METHODS AND RESULTS: Sixty ablation-naïve patients with AF scheduled for first-time catheter ablation were enrolled (78% men, 67% paroxysmal AF, 73% heart failure reduced ejection fraction [HFrEF]). Prior to the procedure, CMRi was performed in sinus rhythm (SR) on a 1.5T system using a high-resolution (1.3 mm isotropic) free-breathing 3D LGE sequence with echo-navigator end-expiratory gating and whole-heart coverage. Left atrium (LA) fibrosis was quantified using the commercially available ADAS 3D software, with fibrosis defined at four image intensity ratios (IIR) thresholds (0.97, 1.2, 1.32, and 1.61 times mean blood-pool signal intensity). High-density electroanatomical mapping (EAM) was performed in SR, and low-voltage substrates (LVS) were quantified at three bipolar voltage thresholds (0.5, 0.25, and 0.1 mV). LVS-EAM were identified in 97%, 88%, and 45% of patients at 0.5, 0.25, and 0.1 mV, respectively. LGE-CMRi was detected in 100%, 97%, 63%, and 17% of patients at IIR thresholds of 0.97, 1.2, 1.32, and 1.61, respectively. Quantitative correlation between CMR- and EAM-derived fibrosis was negligible to weak across all threshold combinations. When fibrosis was analyzed dichotomously, agreement was highest between EAM 0.5 mV and CMR IIR 0.97 (0.97, 95% CI [0.92, 1.00]; p < 0.001) and IIR 1.2 (1, 95% CI [1.00, 1.00]; p < 0.001), and between EAM 0.25 mV and CMR IIR 0.97 (0.87 95% CI [0.76, 0.97]; p < 0.001) and IIR 1.2 (0.9, 95% CI [0.81, 0.99]; p < 0.001).

CONCLUSIONS: In an ablation-naïve AF population with a predominance of HFrEF patients, CMR- and EAM-derived measures of atrial fibrosis showed poor quantitative correlation across multiple threshold combinations. Although agreement improved when fibrosis was analyzed dichotomously (presence vs. absence of fibrosis), the highest agreement was observed at the most sensitive threshold combinations. The findings of our study highlight the need for standardized, validated, and reproducible CMR protocols for native atrial fibrosis assessment in order to provide a noninvasive alternative to EAM.

PMID:42418763 | DOI:10.1111/jce.70447

J Cardiovasc Electrophysiol. 2026 Jul 8. doi: 10.1111/jce.70450. Online ahead of print.

ABSTRACT

BACKGROUND: Intracardiac echocardiography (ICE)-guided left atrial appendage occlusion (LAAO) from left atrium under local anesthesia showed potential advantages over transesophageal echocardiography (TOE). This study sought to demonstrate the intraprocedural efficiency and safety of LAAO with ICE guidance in right atrium.

METHODS: In a multicenter randomized controlled trial to assess whether the imaging quality of a novel DynaSight ICE system (SONOSEMI, Shenzhen, China) is noninferior to the SoundStar (Biosense Webster, USA), a sub-group analysis was performed in patients who underwent LAAO under local anesthesia with ICE guidance in right atrium.

RESULTS: Thirty-three of 66 in the DynaSight group and 30 of 67 in the SoundStar group were performed LAAO with ICE guidance in right atrium. There were no statistical differences between two groups in baseline characteristics including demographics, cardiovascular comorbidities, CHA2DS2-VASc score, and HAS-BLED score. Both ICE systems had similar clear image qualities according to multi-plane assessments for home view, atrial septum and left atrium, and judgments for occluders including displaying location and resolution. There was comparable procedural successful rate for device implantation (100% in the DynaSight group vs. 96.67% in the SoundStar group, p = 0.4762) and occurrence of major peri-procedural complications including tamponade, device embolism, death, major bleeding, and ischemic stroke/transient ischemic attack/systemic embolism (0 of 33 in the DynaSight group vs. 3 of 30 in the SoundStar group, p = 0.1022).

CONCLUSIONS: The DynaSight ICE system has the same clear image quality as the SoundStar, which-guided LAAO with the catheter in right atrium is intraprocedural effective and safe for device implantation.

PMID:42418757 | DOI:10.1111/jce.70450

Neurology. 2026 Aug 11;107(3):e218268. doi: 10.1212/WNL.0000000000218268. Epub 2026 Jul 8.

ABSTRACT

BACKGROUND AND OBJECTIVES: Early-onset dementia (EOD), affecting individuals younger than 65 years, imposes a substantial socioeconomic burden. However, evidence on long-term income trajectories and productivity loss across EOD subtypes remains limited. The aim of this study was to evaluate income trajectories and societal productivity loss in individuals with different EOD subtypes.

METHODS: This retrospective, population-based longitudinal cohort study included all patients with EOD from Kuopio University Hospital and Oulu University Hospital referral area between January 2010 and December 2021. Diagnoses were re-validated through clinical data review. For each study case, 10 randomly selected matched controls were used. Demographics, education, and comorbidities were obtained from national registers. Annual gross income was retrieved from Statistics Finland tax records. The Human Capital Approach was used to calculate productivity losses, in effect by estimating the annual income difference relative to controls using a generalized estimating equation regression model, with panel data spanning 15 years before diagnosis and the year of diagnosis.

RESULTS: The EOD cohort comprised 793 patients (50.4% women; mean age 59.6 years): 421 with Alzheimer disease (AD), 179 with frontotemporal dementia (FTD) spectrum disorders, 46 with α-synucleinopathies (α-SYNUs), and 147 with other EOD etiologies. Compared with 7,926 age-matched and sex-matched controls, patients with EOD showed substantial and progressively increasing productivity loss up to 15 years before diagnosis, with cumulative losses of €74,577 (46,423-102,732) per patient. In the AD group, productivity loss emerged 6 years before diagnosis (€2,767; 95% CI 18-5,515; p = 0.024) and reached €11,431 at diagnosis (95% CI 8,676-14,184; p < 0.001). In the FTD group, loss appeared 11 years before diagnosis (€4,799; 95% CI 433-9,166; p = 0.031) and increased to €16,116 at diagnosis (95% CI 11,671-20,561; p < 0.001). In the α-SYNU group, differences were variable and significant only at diagnosis (€11,284; 95% CI 2,574-19,993; p < 0.011). In the “other EOD” group (predominantly vascular and mixed dementias), productivity loss remained consistently high across the follow-up (e.g., €8,744 at diagnosis; p < 0.001).

DISCUSSION: This large-scale longitudinal study demonstrates significant productivity loss up to 15 years before EOD diagnosis, with variation across dementia subtypes. Earlier recognition and targeted interventions are needed in the future to mitigate the substantial socioeconomic burden of EOD.

TRIAL REGISTRATION INFORMATION: This study is part of DEGE-RWD-research project (protocol registered to ClinicalTrials.gov: NCT06209515), coordinated by Neurocenter Finland.

PMID:42418748 | DOI:10.1212/WNL.0000000000218268

JCO Precis Oncol. 2026 Jul;10(7):e2600158. doi: 10.1200/PO-26-00158. Epub 2026 Jul 8.

ABSTRACT

PURPOSE: Precision medicine has revolutionized oncology; however, tumor biomarkers are not reflective of the heterogeneous cancer population. We evaluated NRG Oncology prostate cancer (PCa) clinical trials for demographic differences among patients with optional biospecimen collection (BC) consent and biospecimen submission (BSub).

METHODS: Data from 19 NRG PCa clinical trials closed before 2015 were analyzed. Patients who consented to BC and completed BSub were evaluated by race, ethnicity, median income, area deprivation index (ADI; categorized as highest v lowest three quartiles), age at enrollment, site, and year of enrollment. T/chi-square tests were used for continuous/categorical variables, respectively, followed by logistic regression.

RESULTS: Of the 15,648 randomized patients eligible for BC, 11,796 (75%) had specimens submitted. In all, 4,598 (82.2%) of 5,597 eligible patients consented for optional BC in nine clinical trials with a separate BC consent process (consent rates by race/ethnicity: 74.1% Black, 72.8% Hispanic/Latino, 83.8% White). A smaller proportion of Black and Hispanic/Latino patients consented to optional BC compared with those who did not (12.1% v 19.5% Black, P < .0001; 3.5% v 5.8% Hispanic, P = .0006). In univariable logistic regression models, high ADI (more socioeconomic disadvantage) was associated with a decreased likelihood for optional BC consent (odds ratio [OR], 0.67 [95% CI, 0.55 to 0.82]; P = .02), but not a decreased likelihood for BSub (OR, 0.74 [95% CI, 0.53 to 1.04]; P = .08). Multivariable models demonstrated that Black/Hispanic/Latino patients were less likely to consent to optional BC, and Black patients were less likely to have BSub (P < .05 for all).

CONCLUSION: White/non-Hispanic patients and those with less socioeconomic disadvantage were more likely to consent to optional BC, whereas Black patients were less likely to have BSub. Targeted solutions are needed to improve biorepository representation so that precision medicine approaches better reflect the cancer population.

PMID:42418740 | DOI:10.1200/PO-26-00158

J Med Internet Res. 2026 Jul 8;28:e89136. doi: 10.2196/89136.

ABSTRACT

BACKGROUND: Digital health literacy (DHL), the ability to seek, understand, and apply digital health information, is increasingly important in the United Kingdom, with a focus on digital transformation within the health service. While digital tools offer potential to improve access and equity, they may exacerbate existing health inequities if segments of the population are unable to engage with them effectively. Understanding the sociodemographic, economic, and social factors associated with DHL is essential to designing inclusive digital health services.

OBJECTIVE: This study aimed to measure DHL among UK adults and identify its sociodemographic, economic, and social associates.

METHODS: A cross-sectional online survey was disseminated to a nationally representative sample of UK adult internet users from November to December 2024. DHL was self-reported using the validated eHealth Literacy Scale (eHEALS), which ranges from 8 to 40. eHEALS score was dichotomized into high and low DHL based on a cutoff of 26. Multivariable logistic regression was used to identify associates of DHL, with missing data handled using multiple imputation by chained equations.

RESULTS: The median eHEALS score was 31 (IQR 27-32); 21% (320/1525) of the participants had low DHL, while 79% (1205/1525) had high DHL. Those aged 65 years and older, compared with those in the age group of 18-44 years, had higher odds of low DHL (odds ratio [OR] 1.43, 95% CI 1.02-2.01; P=.04). Those belonging to a lower social grade also had higher odds of low DHL, compared with those belonging to the higher social grade (OR 1.37, 95% CI 1.05-1.80; P=.02). Females had lower odds of low DHL (OR 0.60, 95% CI 0.46-0.77; P<.001), as did those with an undergraduate or postgraduate degree or higher, compared with those educated to below degree level (undergraduate degree OR 0.52, 95% CI 0.37-0.74, P<.001; postgraduate degree or higher OR 0.58, 95% CI 0.40-0.82, P=.002). Those who socialized daily, compared to those who did this never or rarely, had marginally lower odds of low DHL (OR 0.64, 95% CI 0.42-1.00; P=.05). In subgroup analysis among participants with chronic health conditions, age and social grade were not significant associates of DHL.

CONCLUSIONS: Among UK internet users, male sex, lower educational attainment, lower social grade, less frequent socializing, and older age were statistically significant associates of low DHL. The model’s modest explanatory power suggests that additional factors beyond those examined play an important role. As findings are based on internet users, the prevalence of low DHL in the general population is likely higher than reported. This study provides a partial basis for identifying groups who may benefit from additional support, but intervention design should not rely solely on factors identified here. Inclusive interventions accounting for a broader range of factors are needed to ensure that digital transformation in health care narrows rather than widens health inequities.

PMID:42418731 | DOI:10.2196/89136

Nurs Open. 2026 Jul;13(7):e70668. doi: 10.1002/nop2.70668.

ABSTRACT

AIM: To systematically evaluate the current state of research on symptom clusters in patients with chronic obstructive pulmonary disease (COPD) and the impact of identifying symptom clusters on health-related quality of life (HRQoL) outcomes.

DESIGN: A systematic review.

METHODS: Two reviewers independently screened the studies against the eligibility criteria. Studies were assessed for risk of bias using the Appraisal tool for Cross-Sectional Studies (AXIS tool). Data were extracted using a pre-developed extraction tool and thematically analysed.

DATA SOURCES: Databases searched included EMbase, PubMed, Cochrane Library, China National Knowledge Infrastructure, Wanfang Database and China Science and Technology Journal Database. Searches were conducted from inception to June 12, 2025.

RESULTS: Eighteen studies were included. Symptom clusters were identified using two tool types, including four multi-symptom and 18 single symptom evaluation tools. Common symptom clusters are respiratory-related symptom cluster, psychological-related symptom cluster, sleep-related symptom cluster and fatigue-related symptom cluster. Seven studies found significant negative associations between symptom clusters and HRQoL. Six studies reported the negative effect of each symptom cluster on HRQoL, but only one study showed no association for the sleep-related cluster.

CONCLUSION: The study of COPD symptom clusters still lacked general evaluation tools and statistical methods. Robust studies are needed to deeply explore the differential impact of symptom clusters across various dimensions of HRQoL.

IMPLICATIONS FOR NURSING PRACTICE: Our findings may make symptom management strategies based on the perspective of symptom clusters possible. In clinical practice, nurses should prioritize identifying and intervening in the symptom clusters with the most significant impact on HRQoL, thereby promoting the transformation of the nursing model from ‘single-symptom management’ to ‘multi-symptom collaborative management.’

REPORTING METHOD: This study adheres to PRISMA and SWiM reporting guidelines.

PATIENT OR PUBLIC CONTRIBUTION: No Patient or Public Involvement because of the systematic review.

TRIAL REGISTRATION: PROSPERO: CRD42024606544.

PMID:42418728 | DOI:10.1002/nop2.70668

Nurs Open. 2026 Jul;13(7):e70511. doi: 10.1002/nop2.70511.

ABSTRACT

AIM: The purpose of this study was to investigate Palestinian nurses’ knowledge, beliefs, attitudes and practices towards complementary and alternative medicine (CAM) as well as the factors that influence these behaviours.

DESIGN: A descriptive cross-sectional design was used.

METHODS: A questionnaire was distributed to nurses at healthcare institutions throughout Palestine using social media. Information on knowledge, beliefs, attitudes and practices of CAM was collected, as well as demographic data. SPSS version 20 was used for analysis.

RESULTS: A total of 202 subjects (female, 112; male, 90) participated in the study. The mean knowledge, belief, attitude and practice of CAM scores were 61 out of 80 (75%), 25 out of 43 (58%), 33 out of 54 (61%) and 15 out of 40 (38%), respectively. Knowledge was significantly negatively associated with age and work experience (p < 0.05). Males and lower-income nurses reported stronger beliefs in CAM than other groups (p < 0.05). Attitudes towards CAM were statistically significantly affected by gender, age and chronic disease status (p < 0.05). Regression analyses showed that work experience was a predictor of CAM knowledge. Gender, place of graduation and income were found to be predictors of CAM beliefs. The presence of chronic conditions was also a predictor of the practice of CAM.

PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

PMID:42418723 | DOI:10.1002/nop2.70511

JMIR Form Res. 2026 Jul 8;10:e85388. doi: 10.2196/85388.

ABSTRACT

BACKGROUND: Health care workers continue to experience heightened levels of distress and burnout, which contribute to higher levels of job dissatisfaction, turnover intentions, presenteeism, and staffing shortages.

OBJECTIVE: The aim of this study was to examine how participation in the StressPal Frontline: Essential Resilience Self-Care and Burnout Prevention program influenced health care workers’ stress and resilience. The study also sought to identify specific measures of perceived stress and resilience that were most affected by participation in the program and to explore whether pre-and-post differences varied based on participant characteristics. The StressPal Frontline program is a digital resilience intervention specifically developed for health care workers to enhance psychological flexibility and stress resilience. The self-paced training program, designed for approximately a 6-week period, consists of brief modules, follow-up resources, and a peer engagement community.

METHODS: A pretest-posttest quasi-experimental design was used to assess the effectiveness of the StressPal Frontline program in reducing stress and building resilience among 76 health care workers who voluntarily joined and completed the program. Outcome measures included the Perceived Stress Scale and the Brief Resilience Scale to assess participants’ perceptions of stressful situations and their ability to bounce back from stress. Descriptive statistics, correlation analysis, paired-samples 2-tailed t test, and multiple regression analysis were conducted. The paired-samples t test was calculated at the scale level and item level to evaluate the statistical significance of pretest and posttest mean differences, and the Cohen d statistic was used as a measure of effect size. Statistical analysis for this study was conducted in Excel (Microsoft), SPSS (IBM Corp), and Jamovi (jamovi project).

RESULTS: The results indicated a 1.53-point reduction in the Perceived Stress Scale score after participating in the StressPal Frontline program, suggesting a statistically significant decline in average perceived stress due to participation in the program (P=.004). The corresponding value of Cohen d was 0.34, suggesting a small-to-medium effect of the intervention, StressPal Frontline program, in reducing perceived stress. For the Brief Resilience Scale, pre-and-post difference was not significant at the scale level (P=.07); however, item-level analysis found significant increases in participants’ perception of their ability to bounce back quickly after hard times and handle difficult situations. No significant differences were found in outcome measures based on age, race, ethnicity, professional role, or practice setting.

CONCLUSIONS: The StressPal Frontline program was associated with positive outcomes in reducing perceived stress. Our study also found no statistical differences in outcomes among participants of different age groups, races, ethnicities, occupations, genders, and practice settings. This is an important finding, as it indicates that the StressPal Frontline program may provide positive benefits for reducing stress across professions, settings, and individual characteristics. This program, along with other resources, could be implemented by health care organizations to support workers’ professional development, behavioral health, and well-being.

PMID:42418697 | DOI:10.2196/85388

JMIR Res Protoc. 2026 Jul 8;15:e95287. doi: 10.2196/95287.

ABSTRACT

BACKGROUND: Medical adherence is traditionally defined as the extent to which a person’s behavior corresponds with agreed-upon recommendations from a health care provider. The rapid diffusion of patient-facing digital health applications (DHAs) challenges the direct applicability of this framework to software-mediated interventions. Unlike pharmacological treatments, DHAs automatically generate detailed usage data but lack a broadly accepted standard for determining which specific data points and usage patterns actually constitute “adequate” use across a broad variety of medical indications and population groups. In parallel, DHAs are becoming increasingly embedded in formal regulatory and reimbursement pathways. A notable example is Germany, where recent reforms plan to link at least 20% of reimbursement for Digitale Gesundheitsanwendungen-formally regulated and reimbursed DHAs-to performance-related indicators that implicitly operationalize adherence as a determinant of reimbursable performance. Despite this growing policy relevance, adherence in patient-facing DHAs remains conceptually fragmented and methodologically heterogeneous.

OBJECTIVE: This scoping review aims to map how adherence is conceptualized, operationalized, and measured in the context of patient-facing DHAs, and to explore whether these approaches differ between applications embedded within formal regulatory and/or reimbursement frameworks and those operating outside such settings.

METHODS: This scoping review follows the Joanna Briggs Institute methodology and will be reported in accordance with the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines. PubMed (MEDLINE), Scopus, and Web of Science will be searched for scientific literature published between 2020 and 2025, inclusive. Machine learning-assisted title and abstract screening will be performed using ASReview, following a sampling-based stopping criterion. Three independent reviewers will conduct screening and data extraction. Relevant gray literature will be identified through targeted searches.

RESULTS: Database searches identified 15,403 records (5469 from PubMed/MEDLINE, 6198 from Scopus, and 3736 from Web of Science), which were reduced to 7052 unique records after automated deduplication using Zotero (Corporation for Digital Scholarship). The full results are intended to be submitted to a peer-reviewed journal by the end of 2026.

CONCLUSIONS: Conducted as part of the DEKODE (Digital Health Adhärenz: Konzept und datenbasierte Evidenz) project funded by the German Federal Joint Committee’s Innovation Fund, this review contributes to the development of a conceptual and empirical adherence framework for patient-facing DHAs. Although DEKODE is primarily oriented toward the German Digitale Gesundheitsanwendungen context, this review applies no geographical restrictions, reflecting the value of establishing a broad evidence base before narrowing the focus to country-specific settings and rendering findings relevant for understanding DHA adherence in all geographies. By clarifying how adherence is currently conceptualized, operationalized, and measured, the review will promote more consistent and context-specific generation and interpretation of adherence-related evidence and support evidence-based policy discussions, international harmonization of evidence standards for DHAs, and health economic evaluations in digital health.

PMID:42418694 | DOI:10.2196/95287

JMIR Diabetes. 2026 Jul 8;11:e86651. doi: 10.2196/86651.

ABSTRACT

BACKGROUND: Digital therapeutics integrating continuous glucose monitoring (CGM) with personalized lifestyle coaching can enhance glycemic control in individuals with type 2 diabetes mellitus (T2DM). However, real-world evidence evaluating such multicomponent interventions-combining CGM with nutrition coaching, physiotherapy, and cognitive behavioral therapy within a unified digital platform-remains limited in South Asian populations.

OBJECTIVE: This study aimed to evaluate the effectiveness of an app-based lifestyle-integrated intervention program (Glycemic Lifestyle Intervention in Diabetes Empowerment-CGM; GLIDE-C) on glycemic, anthropometric, lipid profile, quality of life (QoL), and behavioral outcomes, as well as outcomes related to HEOR (health economics and outcomes research), in adults with mildly uncontrolled T2DM.

METHODS: A prospective observational cohort study was conducted among adults aged ≥18 years with confirmed T2DM and baseline hemoglobin A1c (HbA1c) between 7.5% and 9.5%. The intervention was delivered via the Goodflip mobile app, including a 15-day CGM period and a structured analysis of glucose variations, among other clinical assessments, with follow-up on days 15, 30, and 60. The digital intervention combined CGM-guided personalized diet, exercise, and cognitive behavioral therapy plans delivered through the mobile app, supported by multidisciplinary coaching. Primary outcomes were changes in HbA1c, fasting plasma glucose, postprandial glucose, and CGM metrics; secondary outcomes included lipid profile, anthropometric indices, QoL, and behavioral determinants of glycemic improvement.

RESULTS: Eighteen participants (mean age 49.45, SD 10.91 years; n=11, 61.1% male) completed the program. Mean HbA1c decreased by 0.59% (P=.05), with postprandial glucose decreasing by 25.42 mg/dL (P=.06) and time in range increasing by 9.98%. Modest reductions, consistent with the short intervention duration, occurred in low-density lipoprotein cholesterol (-8.38 mg/dL), body fat (-1.13 kg), and waist circumference (-1.56 cm). QoL improved significantly for sleep quality (P=.04). Improvements were also observed for motivation (P=.06), stress management (P=.08), and mood (P=.12), although these changes were not statistically significant. Behavioral analysis demonstrated strong associations with glycemic outcomes; all participants who reduced their consumption of energy-dense, nutrient-poor foods experienced improvements in HbA1c, whereas those who did not reduce energy-dense, nutrient-poor intake showed less favorable outcomes.

CONCLUSIONS: The novel GLIDE-C program demonstrated clinically meaningful improvements in glycemic control, behavioral outcomes, and QoL in adults with T2DM, without pharmacological modification. These findings strengthen the role of integrated, CGM-guided digital therapeutic platforms as an effective adjunct to the conventional standard of care.

PMID:42418692 | DOI:10.2196/86651