Category: Statistics

JAMA Netw Open. 2026 Feb 2;9(2):e2555875. doi: 10.1001/jamanetworkopen.2025.55875.

ABSTRACT

IMPORTANCE: Before elective surgery, direct oral anticoagulants (DOACs) are discontinued following a standardized protocol. However, this could result in insufficient lowering of DOAC levels that could increase bleeding risk.

OBJECTIVE: To estimate the proportion of patients with elevated DOAC levels at the time of elective surgery, evaluate factors associated with DOAC levels, and examine associated blood loss.

DESIGN, SETTING, AND PARTICIPANTS: This cohort study (DOAC Level Prior to Incision [DALI]) assessed adult patients prescribed a DOAC (apixaban, dabigatran, or rivaroxaban) for any indication and at any dose, undergoing an elective procedure requiring DOAC interruption between May 27, 2018, and February 25, 2024, at 2 Dutch hospitals.

EXPOSURE: Standardized interruption protocol (1 day before moderate- and 2 days before high bleeding-risk procedures) with interruption adjustments for the patient’s kidney function.

MAIN OUTCOMES AND MEASURES: Blood was drawn immediately before surgery to determine DOAC levels (by liquid chromatography-mass spectrometry). Proportions of preoperative DOAC levels of 30 ng/mL or higher and their 95% CIs were estimated, stratified by DOAC type and surgical bleeding risk. Factors associated with DOAC levels were identified through multivariable linear regression. Surgical blood loss and 30-day postoperative complications were described according to DOAC concentrations.

RESULTS: The study was terminated after including 257 patients (100 receiving apixaban, 100 receiving rivaroxaban, and 57 receiving dabigatran due to the slow inclusion rate of those receiving dabigatran; median [IQR] age, 72 [66-78] years; 173 male [67%]); 212 patients (82%) underwent a high bleeding-risk operation. Preprocedural DOAC levels were 30 ng/mL or higher in 7.6% (95% CI, 4.9%-11.6%) of patients. Dabigatran and rivaroxaban had similar proportions, whereas 13.1% (95% CI, 7.8%-21.2%) of patients treated with apixaban had levels of 30 ng/mL or higher. Treatment with apixaban, decreased kidney function, and a shorter interruption time were associated with higher levels. Surgical blood loss (median [range], 0 [0-4250] mL) was not associated with DOAC levels. Twelve patients (4.7%; 95% CI, 2.7%-8.0%), who all had DOAC levels less than 30 ng/mL, experienced major bleeding.

CONCLUSIONS AND RELEVANCE: In this cohort study, most patients following the current protocol had DOAC levels less than 30 ng/mL, although the proportion of patients with elevated levels was higher for apixaban. Preoperative DOAC levels were not associated with blood loss during surgery.

PMID:41637074 | DOI:10.1001/jamanetworkopen.2025.55875

JAMA Netw Open. 2026 Feb 2;9(2):e2555896. doi: 10.1001/jamanetworkopen.2025.55896.

ABSTRACT

IMPORTANCE: Equity, diversity, and inclusion (EDI) initiatives are politically polarizing and increasingly adopted in the health care setting. Their broader impact across different health care career types, career stages, and various levels of education remains largely unknown.

OBJECTIVE: To assess EDI programs and their associated outcomes within health care institutions.

DATA SOURCES: A Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) 2020-compliant systematic review searching PubMed, Scopus, Web of Science, CINAHL, and PsychINFO databases from January 2010 to December 2023.

STUDY SELECTION: Two independent reviewers screened studies that assessed EDI programs or policies in health care institutions.

DATA EXTRACTION AND SYNTHESIS: Programs were categorized based on reported outcomes, including participant satisfaction, increased awareness of EDI-related topics, increases in the proportion of underrepresented minority individuals within medical education or the health care workforce, and overall program impact. Odds ratios (ORs) were pooled using a random-effects model. Analyses followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines. Analysis was conducted June 2025.

MAIN OUTCOMES AND MEASURES: Outcome measures included the proportion of diversity among the workforce, employee and patient satisfaction, and the proportion of employees recruited and retained after program implementation.

RESULTS: In total, 43 studies incorporating more than 15 000 individuals involved in EDI programs were included. Interventions were multifaceted, including 14 career advancement and training programs, 16 diversity representation programs, 11 academia and research support initiatives, and the growth of 2 pipeline programs. Furthermore, interventions demonstrated consistent improvement in EDI initiatives, with perceived benefit in promoting underrepresented minority populations. Findings from the meta-analysis of 2 studies showed that minority representation in competitive medical residencies increased after implementation of 2 EDI interventions (OR, 1.73; 95% CI, 1.21-2.47). Among the 43 studies included in the Joanna Briggs Institute assessment of methodological quality, 7 (16.3%) were rated as high quality, 20 (46.5%) as moderate quality, and 16 (37.2%) as low quality.

CONCLUSIONS AND RELEVANCE: In this systematic review and meta-analysis of EDI initiatives in health care institutions, programs were associated with an increased workforce diversity. These findings support the continued use of EDI initiatives to promote a more inclusive and equitable health care culture.

PMID:41637073 | DOI:10.1001/jamanetworkopen.2025.55896

JAMA Netw Open. 2026 Feb 2;9(2):e2556832. doi: 10.1001/jamanetworkopen.2025.56832.

ABSTRACT

IMPORTANCE: Survivors of infant heart surgery for congenital heart disease (CHD) have high risk for neurodevelopmental (ND) disorders; few multistate data report the percentage with ND diagnosis or utilization across health care settings.

OBJECTIVE: To characterize time to and cumulative prevalence of any ND diagnosis and associated health care utilization in the first 5 years after infant heart surgery for publicly insured children.

DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study included children with CHD with a birth hospitalization and infant cardiac surgery between January 2016 and December 2020. Data were obtained from the Merative MarketScan Medicaid Claims Database of deidentified individual Medicaid enrollees across 12 states. Data were analyzed from December 13, 2022, to October 4, 2024.

EXPOSURES: CHD and infant heart surgery.

MAIN OUTCOMES AND MEASURES: Times from index surgery to first ND diagnosis and ND utilization and their cumulative prevalences by 5 years after index surgery.

RESULTS: Among 3147 patients (mean [SD] duration of enrollment, 30.5 [17.4] months), 1686 (53.6%) were male; 619 (19.7%) were Black, 228 (7.2%) were Hispanic, 1051 (33.4%) were White, 145 (4.5%) belonged to additional racial and ethnic groups, and 1108 (35.2%) had missing data on race and ethnicity. Surgery was neonatal (<30 days) in 1518 (48.2%); 709 (22.5%) had a genetic diagnosis; and highest Risk Adjustment for Congenital Heart Surgery (RACHS-2) category was 1 for 945 patients (30.0%), 2 for 915 (29.1%), 3 for 398 (12.9%), 4 for 577 (18.3%), and 5 for 312 (9.9%). The cumulative prevalences of 1 or more ND diagnoses and use of 1 or more forms of ND services were, respectively, 43.5% (95% CI, 42.2%-44.7%) and 80.0% (95% CI, 78.9%-80.9%) at 3 years and 51.7% (95% CI, 50.4%-52.9%) and 82.9% (95% CI, 81.9%-83.8%) at 5 years. Although 1752 (55.7%) had ND screening, fewer had psychological or neuropsychological (207 [6.6%]) or comprehensive developmental (268 [8.5%]) evaluation. Independent risk factors for time to first ND diagnosis were Black race (hazard ratio [HR], 1.14 [95% CI, 1.00-1.30]; P = .04) or Hispanic ethnicity (HR, 1.24 [95% CI, 1.02-1.50]; P = .03) compared with White race and RACHS-2 category 4 (HR, 1.28 [95% CI, 1.09-1.49]; P = .002) or 5 (HR, 1.32 [95% CI, 1.08-1.61]; P = .007) compared with category 1. Independent risk factors for time to first ND utilization included RACHS-2 categories 2 (HR, 1.30 [95% CI, 1.06-1.60]; P = .01), 4 (HR, 1.63 [95% CI, 1.26-2.11]; P < .001), and 5 (HR, 2.25 [95% CI, 1.64-3.10]; P < .001) compared with category 1.

CONCLUSIONS AND RELEVANCE: In this cohort study of publicly insured children who underwent infant heart surgery, the prevalence of ND disorders and utilization of ND services was high. Developmental screening percentages were comparable with those in general pediatric samples, but few children received society-recommended formal ND evaluations.

PMID:41637072 | DOI:10.1001/jamanetworkopen.2025.56832

Evolution. 2026 Feb 4:qpag020. doi: 10.1093/evolut/qpag020. Online ahead of print.

ABSTRACT

The inhibitory cascade model (ICM) of morphogenesis is an effort to link development to the production of variation, which can influence evolutionary trajectories. The ICM proposes that serially developing features, such as molar teeth, are governed by the relative magnitudes of one activating and one inhibiting developmental process. The statistical expectations of the ICM are typically expressed and analyzed on a first-element standardized scale and seem to be a good predictor of molar proportions. However, the ICM has been applied to traits that occur in series but do not develop in sequence and still recovers as good a fit as when applied to serially developing traits. Such an undiscriminating result raises questions about whether the fit of the ICM is an artifact of standardization. The mathematical rendition of the ICM does not correspond with the verbal descriptions of the developmental argument. Applying our novel re-articulation of the ICM to biological, non-biological, and simulated data, we demonstrate that the apparent goodness of fit of the ICM to many biological systems is an artifact of scaling correlated values with a common denominator. There is no evidence supporting the ICM at the developmental, variational, or evolutionary levels.

PMID:41637054 | DOI:10.1093/evolut/qpag020

Eur Arch Paediatr Dent. 2026 Feb 4. doi: 10.1007/s40368-026-01172-4. Online ahead of print.

ABSTRACT

PURPOSE: To assess the influence of deep diaphragmatic breathing exercises on dental anxiety during the dental visits in children aged 7-13 years.

METHODS: A total of 84 healthy participants of both genders were enrolled in this study. The participants were randomly allocated to the deep breathing (DB) group and the conventional treatment-as-usual (TU) control group. All participants underwent psychological evaluation of their behaviour using Frankl’s Rating Scale (FRS), and their anxiety level using the Facial Image Scale (FIS), in addition to a physiological assessment of blood pressure (mmHg) and heart rate (bpm) using a digital blood pressure monitor, and oxygen saturation level (SpO₂%) using a pulse oximeter. These assessments were conducted at the beginning of the dental visit (T0), 5 min after beginning the dental procedure (T1), and at the end of the dental procedure (T2). Collected data were statistically analysed using the Statistical Package for Social Sciences (SPSS) software version 26 to test the significance at p value ≤ 0.05.

RESULTS: The DB and TU groups showed no significant differences in baseline demographics or clinical characteristics (p > 0.05). The mean procedure time was shorter in the DB group than in the TU group (p < 0.05). During and after treatment, a higher proportion of participants in the DB group were rated as “very happy” on the FIS (p < 0.001) and “definitely positive” on the FRS (p < 0.05). Assessment of physiological parameters revealed that the lower systolic and diastolic blood pressure values during treatment were lower in the DB group (p < 0.001). Pulse rate was similarly lower in the DB group, whilst oxygen saturation remained stable across groups (p > 0.05).

CONCLUSION: Diaphragmatic breathing effectively reduced physiological and behavioural indicators of dental anxiety in children, resulting in enhanced cooperation and shortened treatment times. Thus, it may serve as a practical, non-pharmacological approach for enhancing children’s comfort and procedural efficiency during dental treatment.

PMID:41637045 | DOI:10.1007/s40368-026-01172-4

Matern Child Health J. 2026 Feb 4. doi: 10.1007/s10995-026-04234-7. Online ahead of print.

ABSTRACT

The study was conducted to determine the effect of a web-based support program based on the Health Promotion Model (HPM) on healthy lifestyle behaviors, self-efficacy, and prenatal distress in pregnant women with preeclampsia. The study was conducted with 82 pregnant women diagnosed with preeclampsia, 41 of whom were in the web-based support group and 41 in the control group. Participant introduction form, Healthy Lifestyle Behaviors Scale-II (HLBS-II), Self-Efficacy Scale (SES), Prenatal Distress Scale (PDS), pregnant women’s self-monitoring form, and postpartum assessment form were used for data collection. The increase in the total scores of the HLBS-II and the SES and the decrease in the total score of the PDS was found to be statistically significant in the pregnant women in the web support-based group after the web support. The HPM-based web-based support program improved healthy lifestyle behaviors and self-efficacy and reduced prenatal stress levels of pregnant women with preeclampsia but did not contribute to neonatal outcomes. SIGNIFICANCE: Pregnant women diagnosed with preeclampsia often face heightened physiological and psychological challenges. This study demonstrates that a web-based support program structured around the Health Promotion Model (HPM) significantly improves healthy lifestyle behaviors and self-efficacy while reducing prenatal distress in this high-risk population. These findings suggest that digital health interventions are effective, accessible tools for enhancing maternal well-being. By integrating such platforms into standard obstetric care, healthcare providers can offer continuous, evidence-based support that empowers patients to manage their condition more effectively outside of clinical settings.

PMID:41637027 | DOI:10.1007/s10995-026-04234-7

Clin Transl Oncol. 2026 Feb 4. doi: 10.1007/s12094-026-04246-3. Online ahead of print.

ABSTRACT

INTRODUCTION: The indicators of surgical outcomes are handy tools in health management. Futility is a very interesting indicator, because it defines those patients who have undergone a surgical procedure with its morbidity and mortality and who have not benefited from the treatment. Knowledge of the factors that influence futility can help us better select patients with carcinomatosis of ovarian origin.

METHODS: Multicenter study was performed.

INCLUSION CRITERIA: > 18 years old, with ovarian cancer and peritoneal carcinomatosis, who underwent scheduled surgery after response to neoadjuvant therapy. The definition of Futility in ovarian peritoneal carcinomatosis was: all patients with non-CC-0, death in the first 90 days in the postoperative period or within the first year after surgery were considered futile patients.

RESULTS: We included 365 patients. 84 patients (23.6%) were in the futility group compared with 279 (73.4%) who were not in the futility group. We obtained that non-obtaining CC-0 was the main factor of futility (61.6%). The 2º crucial factor of futility was mortality in the first year after surgery. The incidence of futility in the series is 23.6%. Comparing futility and non-futility groups, we could observe statistically significant differences in hospital stay, higher levels of CA125 (52 vs. 35), and higher postoperative PCI. Patients in the futility group had almost twice PCIs as those who were not. When performing univariate regression, we could observe that PCI and the PCI distributed by categories (< 10; 11-20; > 20) were independent variables associated with futility.

CONCLUSION: PCI is a relevant factor in futility in ovarian cancer.

PMID:41637003 | DOI:10.1007/s12094-026-04246-3

Aging Clin Exp Res. 2026 Feb 4. doi: 10.1007/s40520-026-03331-5. Online ahead of print.

ABSTRACT

OBJECTIVE: To examine the association of changes in loneliness with subsequent cardiometabolic comorbidity (CMM) among middle-aged and older Chinese and South Korean adults.

METHODS: We used the harmonized individual-level data from the China Health and Retirement Longitudinal Study (CHARLS, n = 9381) from China and the Korean Longitudinal Study of Aging (KLoSA, n = 5052) from South Korea. In both CHARLS and KLoSA, loneliness was measured using a single item from the 10-item Center for Epidemiological Studies Depression Scale (CESD-10) at baseline and in the second survey. CMM was defined as the presence of two or more cardiometabolic conditions, including diabetes, heart disease, and stroke, based on physician-diagnosed self-report. Within each cohort, we used the multivariable Cox proportional hazards models to estimate adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs) of incident CMM according to changes in loneliness (never, initiated, relieved, and persistent) over 7 years (CHARLS) or 6 years (KLoSA) of follow-up.

RESULTS: In CHARLS, initiated (aHR 1.42, 95%CI 1.14-1.78), relieved (aHR 1.40, 95%CI 1.16-1.70), and persistent (aHR 2.03, 95%CI 1.64-2.51) loneliness were associated with an increased likelihood of experiencing CMM. In KLoSA, both relieved (aHR 1.72, 95%CI 1.07-2.76) and persistent (aHR 1.86, 95%CI 1.21-2.88) loneliness were significantly associated with CMM, whereas the initiated loneliness showed no significant association (aHR 1.25, 95%CI 0.76-2.07).

CONCLUSIONS: Changes in loneliness were associated with an increased risk of subsequent CMM in both China and South Korea, with the strongest associations observed among individuals experiencing persistent loneliness. These findings indicate that loneliness is a dynamic and potentially modifiable risk factor for cardiometabolic multimorbidity across different sociocultural contexts. Early identification and targeted interventions addressing loneliness may contribute to the prevention of CMM among middle-aged and older adults.

PMID:41636996 | DOI:10.1007/s40520-026-03331-5

Pharmacoeconomics. 2026 Feb 4. doi: 10.1007/s40273-025-01585-x. Online ahead of print.

ABSTRACT

OBJECTIVES: Bevacizumab was approved for first-line treatment of metastatic colorectal cancer (mCRC) in 2004. However, adding bevacizumab to treatment consistently fails to be cost-effective owing to modest response rates. Recently, the European Commission (EC) funded ANGIOPREDICT consortium ( www.angiopredict.com ) identified a link between bevacizumab treatment response and intermediate-to-high chromosomal instability (CIN) in mCRC. Thus, the objective of the current study was to compare the cost-effectiveness of adding bevacizumab with first-line chemotherapy in the bevacizumab responsive CIN subtype across three European countries (Germany, Ireland and Spain) with varying costs of care and reimbursement policies.

METHODS: We developed an open-source health economic model to estimate cost-effectiveness. The ANGIOPREDICT cohort informed progression risks and cause-specific mortality. Health utilities and adverse events probabilities were obtained from the literature. Costs were derived from surveys of collaborating consortium hospitals in Germany, Ireland, and Spain that participated in the recently completed EC funded COLOSSUS translational study (ANGIOPREDICT successor initiative) and the literature. Sensitivity analyses included individual and simultaneous variation of input parameters from a priori defined distributions.

RESULTS: Bevacizumab was not cost effective even at willingness-to-pay (WTP) thresholds that are appreciably higher than those considered realistic. The highest incremental cost-effectiveness ratio (ICER) was in Germany at €241,188 per quality-adjusted life year (QALY), while the lowest was in Ireland at €180,477 per QALY. All deterministic and probabilistic sensitivity analyses demonstrated that these results were robust.

CONCLUSIONS: Even for patients with mCRC manifesting improved outcomes, adding bevacizumab to first-line chemotherapy is invariably not cost-effective in any of the countries examined. Variability in pricing, healthcare costs and WTP thresholds across countries did not commute this result.

PMID:41636995 | DOI:10.1007/s40273-025-01585-x

Odontology. 2026 Feb 4. doi: 10.1007/s10266-026-01323-5. Online ahead of print.

ABSTRACT

The purpose of this randomized clinical trial was to compare the analgesic effectiveness of sublingual administration of wheatgrass (WG) and piroxicam, a non-steroidal anti-inflammatory drug (NSAID), for patients with symptomatic irreversible pulpitis, with or without apical periodontitis. Forty-five patients aged 18-40 years were recruited and randomly allocated into three groups receiving the sublingual drug administration: Group 1-WG (500 mg); Group 2-Piroxicam (20 mg); Group 3-Placebo sugar tablet (20 mg) (control). Pain intensity was assessed using the Numerical Pain Rating Scale (NPRS; 0-10) prior to administration and again 30 min after the respective interventions. The onset of analgesic action was also recorded for each participant. Statistical comparisons among the groups were conducted using one-way ANOVA with the significance threshold set at p < 0.05. Both sublingual WG and piroxicam demonstrated significantly greater reductions in pain scores compared with the placebo group after 30 min. Notably, participants receiving WG exhibited a significantly higher degree of pain reduction than those receiving piroxicam. These findings suggest that WG may offer a rapid and effective analgesic response when administered sublingually. Given its natural origin, WG may serve as a promising adjunct or alternative to conventional NSAIDs for the short-term management of acute dental pain associated with symptomatic irreversible pulpitis.Trial registration: This clinical trial was prospectively registered in Clinical Trial Registry of India under the registration number of CTRI/2024/12/078719 dated on 30/12/2024 ( https://www.ctri.nic.in/ ).

PMID:41636988 | DOI:10.1007/s10266-026-01323-5