Category: Statistics

Breast. 2025 Sep 17;84:104581. doi: 10.1016/j.breast.2025.104581. Online ahead of print.

ABSTRACT

BACKGROUND: Adjuvant radiotherapy (RT) for early-stage breast cancer is associated with increased major cardiovascular (CV) events. This study investigates cardiac toxicity in an Asian breast cancer cohort, focusing on the interplay between RT, cardiovascular risk factors, and systemic treatments, a topic less explored in regions with lower cardiovascular disease (CVD) prevalence.

METHODS: Patients with breast cancer who underwent adjuvant RT between January 2004 and November 2014 were included in this single-institutional retrospective study. Patients were categorized by CVD risk factors, including obesity, smoking history, prior CVD incidents, chronic kidney disease (CKD), diabetes mellitus, hypertension, and dyslipidemia. The primary outcome was the incidence of major CV events, defined as conditions requiring intervention, including heart failure, arrhythmia, and ischemic heart disease. Kaplan-Meier methods, log-rank tests, and Cox regression models were used for statistical analysis.

RESULTS: Among the 975 patients, the 10-year cumulative incidence of major CV events was 3.7 %, with no significant difference (p = 0.892) between right-sided (3.8 %) and left-sided RT (3.4 %). Patients with low, intermediate, and high CVD risk factors had 10-year cumulative incidences of 0.7 %, 2.5 %, and 13.7 %, respectively. Multivariate analysis revealed that hypertension, CKD, and previous CVD were significantly associated with major CV events. In patients without CVD risk factors, the 10-year incidence of CV events was higher in those undergoing left-sided RT compared to right-sided RT (1.3 % vs. 0.0 %, p = 0.032).

CONCLUSIONS: Major CV events incidences following RT in this Asian cohort with low baseline CVD risk were modest. However, the impact was more pronounced in patients without baseline CVD risk factors, emphasizing the need for personalized risk assessment in RT planning.

PMID:40991981 | DOI:10.1016/j.breast.2025.104581

Am J Sports Med. 2025 Sep 24:3635465251376586. doi: 10.1177/03635465251376586. Online ahead of print.

ABSTRACT

BACKGROUND: The femoral attachment of the anterolateral ligament (ALL) reported by anatomic studies is posterior and proximal to the lateral femoral epicondyle.

PURPOSE: To assess the femoral positioning of the ALL graft while performing a percutaneous technique and evaluate the correlation between this positioning and the graft rupture rate, as well as clinical and functional outcomes.

STUDY DESIGN: Cohort study; Level of evidence, 3.

METHODS: A total of 211 patients undergoing combined anterior cruciate ligament (ACL) and ALL reconstruction were included. Radiological measurements, Knee injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee (IKDC) score, and graft failure rate were collected at 24 months after surgery.

RESULTS: The rate of anatomic positioning of ALL femoral anchors was 79.1% (n = 167). The mean proximal and posterior distances relative to the ALL anatomic femoral position were 1.4 ± 2.8 mm and 0.2 ± 0.2 mm, respectively. The rate of outliers, defined as >5 mm from the anatomic position, was 20.85% (n = 44). The mean KOOS and IKDC score were 84 ± 10.9 and 80.1 ± 11.3, respectively. No statistically significant difference in KOOS and IKDC score was observed between the group of patients with anatomic positioning and the group of outliers (P = .1). The rate of ACL rerupture for all patients was 3.79% (n = 8). Of these, 87.5% (n = 7) were outliers. The correlation between ALL femoral malpositioning and ACL rerupture was statistically significant (P < .00001).

CONCLUSION: Independent ALL reconstruction while performing a percutaneous technique enabled anatomic positioning of the ALL graft in 79% of cases. The femoral malpositioning was correlated with a higher ACL graft rerupture rate but not with a decrease in the functional outcomes.

PMID:40991962 | DOI:10.1177/03635465251376586

Ultrasound Obstet Gynecol. 2025 Sep 24. doi: 10.1002/uog.70099. Online ahead of print.

ABSTRACT

OBJECTIVE: To investigate the risk of adverse obstetric and neonatal outcomes in patients with unexplained recurrent implantation failure (uRIF) who had a singleton live birth.

METHODS: This multicenter retrospective cohort study reviewed 49 372 embryo-transfer cycles leading to a singleton live birth at three fertility centers in China between January 2014 and July 2021. Patients were categorized into the uRIF group if they had a history of at least three failed transfers of unknown cause with at least four good-quality embryos, while the control group comprised women who had experienced fewer than three failed implantation cycles. Obstetric and neonatal outcomes were collected via telephone interviews using a standardized questionnaire. Propensity score matching (PSM) and multivariate logistic regression analysis were used to control for potential confounders.

RESULTS: After exclusions, 1244 patients with a history of uRIF and 36 644 controls were included in the study. All baseline characteristics were balanced following PSM, with 1243 patients retained in each group. Compared with the control group, the uRIF group exhibited significantly higher odds of placenta previa (2.7% vs 1.4%; adjusted odds ratio (aOR), 2.01 (95% CI, 1.01-4.00)), placental abruption (0.3% vs 0%; aOR, 6.51 (95% CI, 1.57-26.91)), Cesarean delivery (76.6% vs 71.8%; aOR, 1.27 (95% CI, 1.06-1.53)) and preterm birth (10.1% vs 7.3%; aOR, 1.44 (95% CI, 1.08-1.91)). The results remained consistent on sensitivity analysis using prematched data with multivariate adjustment.

CONCLUSIONS: A history of uRIF was associated with increased risks for placenta previa, placental abruption, Cesarean delivery and preterm birth. While statistically significant, the absolute differences in the rates of these complications were modest and the clinical relevance of our findings should be interpreted with caution. © 2025 International Society of Ultrasound in Obstetrics and Gynecology.

PMID:40991952 | DOI:10.1002/uog.70099

JMIR Med Educ. 2025 Sep 24;11:e70726. doi: 10.2196/70726.

ABSTRACT

BACKGROUND: Burnout among emergency room health care workers (HCWs) has reached critical levels, affecting up to 43% of HCWs and 35% of emergency medicine personnel during the COVID-19 pandemic. Nurses were most affected, followed by physicians, leading to absenteeism, reduced care quality, and turnover rates as high as 78% in some settings such as Thailand. Beyond workforce instability, burnout compromises patient safety. Each 1-unit increase in emotional exhaustion has been linked to a 2.63-fold rise in reports of poor care quality, 30% increase in patient falls, 47% increase in medication errors, and 32% increase in health care-associated infections. Burnout is also associated with lower job satisfaction, worsening mental health, and increased intent to leave the profession. These findings underscore the urgent need for effective strategies to reduce stress and burnout in emergency care.

OBJECTIVE: This study aimed to evaluate the effectiveness and effect size of a multimodal learning approach-Emergency Room Virtual Simulation Interprofessional Education (ER-VIPE)-that integrates medical movies, massive online open courses (MOOCs), and computer- or virtual reality (VR)-based simulations with co-debriefing for reducing burnout and stress among future health care professionals compared with approaches lacking co-debriefing or using only movies and MOOCs.

METHODS: A single-blind, quasi-experimental study was conducted at a university hospital from August 2022 to September 2023 using a 3-group treatment design. Group A (control) participated in a 3D computer-based, simulation-based interprofessional education (SIMBIE) without debriefing. Group B received the ER-VIPE intervention. Group C received the same as Group B, but the computer-based SIMBIE was replaced with 3D VR-SIMBIE. SIMBIE activities simulated a COVID-19 pneumonia crisis. Outcomes included the Dundee Stress State Questionnaire (DSSQ) and the Copenhagen Burnout Inventory, with trait anxiety as a behavioral control. Stress and burnout were measured at baseline, pre-intervention, postintervention, and 1-month follow-up. Generalized estimating equations were used to analyze group differences, with statistical significance set at P<.05.

RESULTS: We randomized 87 undergraduate students from various health programs into the 3 groups (n=29 each). Participants’ mean age was 22 years, with 71% (62/87) as women. After the 1-month post-SIMBIE follow-up, adjusted analyses revealed positive trends in DSSQ-engagement across all groups, with Group B showing a significant increase compared with Group A (mean difference=3.93; P=.001). DSSQ-worry and DSSQ-distress scores decreased nonsignificantly across all groups. Burnout scores also improved across groups, with Group B having a significantly lower score than Group A (mean difference=-2.02; P=.02). No significant burnout differences were found between Group C and Groups A or B.

CONCLUSIONS: A multimodal learning approach combining medical movies, MOOCs, and 3D computer-based SIMBIE with co-debriefing effectively improved engagement, reduced stress, and lowered burnout among future health care professionals. This scalable educational framework may help enhance well-being and resilience in high-pressure clinical environments.

PMID:40991944 | DOI:10.2196/70726

JMIR Res Protoc. 2025 Sep 24;14:e75796. doi: 10.2196/75796.

ABSTRACT

BACKGROUND: According to the World Health Organization’s infant and young child feeding guidelines, infants should be exclusively breastfed for the first 6 months of life. Despite public health campaigns to increase exclusive breastfeeding (EBF) rates, socioeconomic inequities persist among low-income breastfeeding mothers, especially in countries with large wealth and health gaps, such as Brazil. Social transfer programs are initiatives that provide financial support to individuals or households to improve their well-being and reduce financial burdens. These may be conditional, requiring recipients to meet specific criteria to receive the transfer, or unconditional, in which recipients receive the transfer without prerequisites. Evidence suggests that conditional and unconditional social transfers may help increase EBF rates while addressing the economic challenges breastfeeding mothers face. A randomized controlled trial (RCT) conducted in Vientiane, Lao People’s Democratic Republic, found that a social transfer program significantly improved both EBF rates at 6 months and EBF duration. Building on this study, we aim to evaluate the impact of this intervention in a different socioeconomic and cultural context.

OBJECTIVE: This protocol aims to implement an RCT to assess whether conditional and unconditional social transfers improve EBF rates at 6 months postpartum for mothers in low-income communities in São Paulo, Brazil.

METHODS: A prospective RCT will be conducted among 400 mothers who gave birth in the last 72 hours and plan to exclusively breastfeed. Participants will be recruited in São Paulo at the University Hospital of São Paulo and Amparo Maternal. Participants will be randomly assigned to one of the following groups: (1) control group-no social transfer; (2) intervention group 1-an unconditional social transfer at 6 months postpartum; and (3) intervention group 2-a social transfer at 6 months postpartum, conditional upon mothers’ EBF. All groups will receive educational materials supporting EBF. The study will have visits at birth, 1 month, 6 months, 1 year, and 2 years and will include a questionnaire and biological collections of breast milk samples, infant fecal samples, and blood samples (finger pricks) from both the mother and infant. The main study outcomes are the prevalence of EBF at 6 months and the duration of EBF across the 3 groups, where we hypothesize higher rates of EBF among mothers in the conditional group.

RESULTS: Recruitment began on March 6, 2024. As of September 2025, we enrolled 204 participants. Our goal is to recruit 400 mother-infant dyads by October 2025, with study visits expected to be completed by October 2027.

CONCLUSIONS: We hypothesize that the Social Transfers for Exclusive Breastfeeding in Brazil (STEBB) intervention will positively impact breastfeeding mothers in São Paulo. If successful, the program may inform national policy to enhance Brazil’s existing social transfer program for new mothers.

TRIAL REGISTRATION: ClinicalTrials.gov NCT06157697; https://clinicaltrials.gov/study/NCT06157697.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/75796.

PMID:40991943 | DOI:10.2196/75796

JMIR Mhealth Uhealth. 2025 Sep 24;13:e71213. doi: 10.2196/71213.

ABSTRACT

BACKGROUND: Consumer wearable technology quantifies physical activity; however, the association between these metrics and cardiometabolic health requires further elucidation.

OBJECTIVE: This study identified latent factors derived from Fitbit heart rate metrics and their relationship with cross-sectional cardiovascular phenotypes.

METHODS: This cross-sectional analysis included 457 participants from the SingHEART study, a multiethnic, population-based study of Asian individuals aged 21 to 69 years recruited in Singapore. Participants wore the Fitbit Charge HR for 7 days, and data on physical activity metrics, self-reported physical activity index (PAI), blood tests, coronary artery calcium scores, and cardiac magnetic resonance imaging were collected. Exploratory factor analysis identified latent factors from Fitbit metrics, and multivariate regression analysis assessed associations with blood and cardiovascular imaging phenotypes.

RESULTS: Higher levels of self-reported PAI were significantly associated with a higher number of calories burned (P=.008), number of steps and floors climbed, distance, number of activity calories, and number of very active minutes (P<.001). However, there was no association between PAI and other Fitbit metrics. Using exploratory factor analysis, we identified three latent factors measured by Fitbit metrics: (1) elevated metabolic equivalents of task (METs; calories burned per day, minutes per day spent fairly active in 3-6 METs and very active in ≥6 METs, and activity calories), (2) total activity (steps per day, distance in kilometers per day, and number of floors per day), and (3) others, all with a Cronbach α of >0.7. Higher total activity was associated with increased high-density lipoprotein levels (β=0.06; P<.001), decreased triglyceride levels (β=-0.10; P=.006), and lower BMI (β=-0.63; P<.001) after adjustment for age, gender, systolic blood pressure, total cholesterol, and family history of heart disease. The interaction between total activity and elevated METs was associated with lower fasting glucose (β=-0.07; P=.004). Elevated METs were associated with higher log(coronary artery calcium+1) and higher BMI (P<.001). Total activity was significantly associated with higher indexed biventricular systolic (P=.01 for left and P=.006 for right) and diastolic volumes (P<.001) and higher indexed left ventricular mass (P=.005).

CONCLUSIONS: We identified 3 groups of wearable metrics with distinct characteristics. While total activity had a significant relationship with self-reported PAI, most metrics of elevated METs did not. Total activity had a consistent and favorable association with lipid and glucose profiles and a dose-dependent association with cardiac remodeling. Elevated METs alone did not appear to have a significant association with favorable cardiovascular profiles. This study suggests that the total activity metrics are robust and dependable when interpreting an individual’s activity levels, with construct validity according to self-reported PAI and a positive association with lipid and glucose profiles, and demonstrate dose-dependent associations with cardiac remodeling after adjustment for demographics and risk factors. Findings related to elevated METs may be due to the Hawthorne effect and require further studies.

PMID:40991940 | DOI:10.2196/71213

Mil Med. 2025 Sep 24:usaf472. doi: 10.1093/milmed/usaf472. Online ahead of print.

ABSTRACT

INTRODUCTION: U.S. Active duty Service members (ADSMs) experience barriers to sexual and reproductive healthcare (SRH). Enhancing patient-centered SRH services is essential to empowering ADSMs to achieve their health goals, which may, in turn, contribute to improved military readiness. This study aimed to assess the feasibility and acceptability of a clinician-led group educational intervention developed to improve ADSMs’ awareness of availability of SRH services and self-efficacy to access this care, in order to guide future refinement and implementation of this program.

MATERIALS AND METHODS: A series of standardized 20-minute, interactive group educational sessions on SRH topics was delivered over a 12 month period to groups of ADSMs at a large military installation. This pretest-posttest study was conducted without a control group to assess feasibility. The primary outcomes were changes in perceived SRH knowledge and intention to seek future SRH, and were evaluated with McNemar’s tests. Logistic regression evaluated the influence of demographic characteristics on these changes.

RESULTS: Participants included 1,077 ADSMs (72% male, 89% junior enlisted). Exposure to the intervention was associated with increased awareness of contraceptive options (pre = 81%/post = 96%), available SRH services (pre = 60%/post = 96%), how to obtain emergency contraception (pre = 57%/post = 96%), human immunodeficiency virus (HIV) pre-exposure prevention (pre = 40%/post = 92%), and how to request sexually transmitted infection (STI) screening (pre = 51%/post = 96%), (ps < 0.001). Participants indicated increased intent to schedule an appointment for STI screening (pre = 8%/post = 17%, P < .001) and contraception (female participants pre = 18%/post = 26%, P = .008). Of those who did not agree that they were comfortable discussing SRH with a military clinician on the pre-intervention questionnaire, 77% reported that they were more encouraged to use SRH services on a military base, and 76% reported that they were more comfortable seeking SRH services in a military clinic after the intervention. Logistic regression showed no statistically significant effects of demographic characteristics on responses to the intervention. One-third of participants requested an appointment after the intervention using an appointment request card. Almost all participants (i.e., 87%) reported plans to share the content.

CONCLUSIONS: This patient-centered initiative is feasible and acceptable to ADSMs, may be scalable, and has the potential to reduce barriers and empower ADSMs in optimizing their SRH goals.

PMID:40991924 | DOI:10.1093/milmed/usaf472

Mil Med. 2025 Sep 24:usaf429. doi: 10.1093/milmed/usaf429. Online ahead of print.

ABSTRACT

INTRODUCTION: Exertional heat illness (EHI) is a threat to force health and readiness. EHI recovery can entail lengthy periods of lost duty time as providers ensure that patients have completely recovered and that the risk for recurrent EHI is low. Although EHI recurrence is a common concern, there is little research to inform or predict EHI recurrence. Here we describe characteristics associated with EHI duty restrictions and use them to predict EHI recurrence and prognosis.

MATERIALS AND METHODS: We studied a retrospective cohort of 1,742 US Army soldiers who received EHI duty restrictions because of a recent EHI diagnosis between July 2014 and April 2017. We used EHI complications, medical history, and demographics to predict EHI recurrence. The study protocol was approved by the Naval Medical Center Portsmouth Institutional Review Board.

RESULTS: 4.4% of soldiers had recurrent EHI. Among soldiers receiving an EHI profile, a history of another prior EHI was rare (5.6%) but was strongly associated with recurrent EHI (HRadj: 7.37, 95% CI: 4.24-12.81). These associations were consistent across heat exhaustion (HE), heat injury (HI), and heat stroke (HS) cases. Shorter profile durations were associated with reduced risk for recurrence, but this association was mostly attributable to milder EHI events. Based on total duty restriction days, HI represented a greater disease burden than HS or HE. Recurrent EHI was more common among soldiers who had been on an HI (4.6%) or HS (6.1%) profile than an HE profile (3.7%), although these differences were not statistically significant. Clinical complications (e.g., kidney injury, rhabdomyolysis, respiratory/cardiovascular distress, inpatient/ICU admission) were not associated with EHI recurrence.

CONCLUSIONS: Among soldiers on EHI duty restrictions, prior EHI is rare but strongly associated with risk for yet another EHI. The clinical characteristics (e.g., profile duration, complications) of a prior EHI were not associated with risk for recurrent EHI. Further research should characterize the role of EHI severity in return to duty and validate HI as a diagnostic category.

PMID:40991920 | DOI:10.1093/milmed/usaf429

J Neuropathol Exp Neurol. 2025 Sep 24:nlaf104. doi: 10.1093/jnen/nlaf104. Online ahead of print.

ABSTRACT

We investigated the expression and distribution of 5 cytoadhesion receptors for the Plasmodium falciparum erythrocyte membrane protein 1 in 12 regions of post-mortem brains of 50 Malawian children, that is, 27 with the clinical and pathological diagnosis of cerebral malaria (CM) and 23 with a non-malarial cause of death. We quantified the expression of each receptor by microvascular endothelium and the colocalization of receptor-expressing microvessels with sequestered infected red blood cells (iRBC) and calculated a receptor-independent sequestration ratio. There were differences in the level of expression and regional distribution of the five receptors: ICAM-1 was the most widely expressed receptor, followed by CD36, VCAM-1, E-selectin, and thrombospondin. Receptor-expressing microvessels were most numerous in the frontal lobe and least numerous in the brainstem and cerebellum. Colocalization of receptor-expressing endothelial cells with iRBC was present in all brain regions; it was highest for ICAM-1 and CD36 and greatest in the frontal lobe. The sequestration ratios were close to 100% for all receptors across all brain regions and were similar in cerebral and extracerebral microvessels. Receptor expression and colocalization ratios were greater in the brain than in the lung, heart, liver, spleen, and subcutaneous tissue. These differences in cerebral endothelial expression of cytoadhesion receptors and their preferential regional distribution may underpin differences in iRBC sequestration and lesion development in CM. Moreover, greater expression of these receptors in the brain vs peripheral organs may explain a comparatively greater degree of iRBC sequestration in the brain.

PMID:40991892 | DOI:10.1093/jnen/nlaf104

Neurology. 2025 Oct 21;105(8):e214226. doi: 10.1212/WNL.0000000000214226. Epub 2025 Sep 24.

ABSTRACT

BACKGROUND AND OBJECTIVES: Cognitive disability-defined by the Behavioral Risk Factor Surveillance System (BRFSS) as serious difficulty concentrating, remembering, or making decisions because of a physical, mental, or emotional condition-has become the most commonly reported disability among US adults. This broad definition reflects a heterogeneous range of underlying causes and highlights the growing public health significance of cognitive disability in the population. Previous studies have identified disparities by race, age, and socioeconomic status, but few have examined how these patterns have evolved over the past decade. This study analyzes national trends in self-reported cognitive disability from 2013 to 2023 using BRFSS data, with a focus on differences across age groups, racial and ethnic populations, and key social determinants of health.

METHODS: We conducted a retrospective analysis using data from the Centers for Disease Control and Prevention’s Disability and Health Data System, which integrates nationally representative responses from US adults (aged ≥18 years) in the BRFSS from 2013 to 2023, excluding 2020 and participants who self-reported depression, to better identify nonpsychiatric cognitive impairment. The primary outcome was self-reported cognitive disability, defined as “serious difficulty concentrating, remembering, or making decisions.” Survey-weighted logistic regression was used to model prevalence trends and examine associations with demographic and socioeconomic factors.

RESULTS: From 2013 to 2023, a total of 4,507,061 responses were included in the analysis. Apart from analyses focusing on strata of age, all estimates of cognitive disability were age-adjusted. Most respondents were aged 18-39 years (36.8%), identified as non-Hispanic White (60.9%), and had completed at least a high school education (87.3%). The age-adjusted self-reported cognitive disability prevalence in the United States rose from 5.3% (95% CI 5.1%-5.4%) in 2013 to 7.4% (95% CI 7.2%-7.6%) in 2023, with statistically significant increases beginning in 2016. The prevalence of cognitive disability among younger adults aged 18-39 years nearly doubled, increasing from 5.1% (95% CI 4.8%-5.3%) to 9.7% (95% CI 9.2%-10.2%), making this age group the primary driver of the overall rise in cognitive disability in the United States.

DISCUSSION: The disproportionate growth in cognitive disability among younger adults seems to be the primary driver of the overall national trend. These findings warrant further investigation, given their potential long-term implications for population health, workforce productivity, and health care systems.

PMID:40991889 | DOI:10.1212/WNL.0000000000214226