Category: Statistics

JAMA Health Forum. 2025 Sep 5;6(9):e253192. doi: 10.1001/jamahealthforum.2025.3192.

ABSTRACT

IMPORTANCE: Subspecialists-physicians with narrower clinical focus-play an increasing role in US health care, particularly in surgery, where most trainees now pursue fellowship training. Yet little is known about the degree of subspecialization among practicing surgeons and the evolving role of surgical generalists.

OBJECTIVE: To quantify trends in surgical subspecialization and examine the geographic distribution of subspecialists and the procedural scope of surgical generalists.

DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort study using 100% Medicare Part B data from 2000, 2010, and 2021, including all fee-for-service beneficiaries treated by physicians in general surgery, neurosurgery, ophthalmology, orthopedic surgery, and otolaryngology was caried out. A novel classification method combining k-means clustering, large language models, and expert validation to distinguish subspecialists from surgical generalists based on procedural claims was used. The analysis was undertaken in 2023 and 2024.

MAIN OUTCOMES AND MEASURES: The number of distinct subspecialties, the share of subspecialists in each surgical specialty, their geographic distribution across hospital referral regions (HRRs), and the association between subspecialist supply and procedural diversity among generalists.

RESULTS: Overall, more than 70 000 surgeons were included. The share of subspecialists increased from 38% in 2000 to 58% in 2021, reflecting the growth of recognized subspecialties (from 24 to 33) and expansion of existing ones. Subspecialization rates varied by specialty, rising from 9% to 28% in otolaryngology and from 66% to 77% in neurosurgery. While subspecialist supply per 100 000 fee-for-service beneficiaries remained stable, the mean number of surgical generalists per 100 000 declined from 105 to 50. A 10% increase in subspecialist supply in an HRR was associated with a 0.94% decrease (95% CI, -0.15% to -0.41%) in the number of unique procedures performed by generalist surgeons.

CONCLUSIONS AND RELEVANCE: This cohort study found that subspecialization has considerably reshaped the surgical workforce, concentrating care among subspecialists while narrowing the procedural scope of generalist surgeons. These shifts raise concerns about access to generalist care, particularly in regions with declining generalist supply, and suggest the need for policies that consider both specialization and geographic equity in surgical workforce planning.

PMID:40971167 | DOI:10.1001/jamahealthforum.2025.3192

JAMA Health Forum. 2025 Sep 5;6(9):e253489. doi: 10.1001/jamahealthforum.2025.3489.

ABSTRACT

IMPORTANCE: Overdoses involving methamphetamines and cocaine have increased in recent years. Identification of individuals at highest risk could facilitate the implementation of evidence-based interventions to reduce overdose risk.

OBJECTIVE: To develop and internally validate a model that predicts hospitalization or emergency department (ED) treatment for stimulant-involved overdose among the Medicaid-insured population.

DESIGN, SETTING, AND PARTICIPANTS: This was a retrospective case-cohort study using Medicaid claims data from 2016 to 2019 (development) and 2020 (validation) for all Medicaid enrollees age 15 years or older with a cocaine- or other stimulant-involved overdose. A subcohort was created using a simple random sample of the full cohort of all cases. Within the full cohort, cases were identified as those having any inpatient or ED encounter for stimulant-involved overdose during the following year. A case-cohort sample was obtained for each calendar year from 2016 to 2020, each with a subcohort size of 100 000. Each individual contributed only 1 case event (for an individual with multiple overdoses, only the first eligible was selected). For each of the 4 overdose outcomes, a predictive weighted Cox model was first developed among enrollees of sampling years 2016 to 2019 (development set), and its performance was evaluated in our test set of 2020. The prediction models were first developed in November 2023, and the model fairness assessment was performed in April to May 2025.

INTERVENTIONS OR EXPOSURES: Individual-level candidate predictors were demographic characteristics, enrollment, health care utilization, and other clinical variables. Area-level variables included social, economic, housing, and demographic characteristics data from the American Community Survey, rural-urban classification, Social Deprivation Index, retail opioid dispensing rates, and health resources.

MAIN OUTCOMES AND MEASURES: Four types of stimulant-involved overdose associated with hospitalization or ED treatment: cocaine-involved overdose, (1) involving an opioid or (2) not involving an opioid; or methamphetamine-, ecstasy-, or other psychostimulant-involved overdose (hereafter, other stimulant), (3) involving an opioid or (4) not involving an opioid.

RESULTS: The analysis included 78 795 enrollees with cocaine- and other stimulant-involved overdose (mean [SD] age, 42.2 [13.7] years; 33 304 [42%] female and 45 491 [58%] male individuals). Weighted Cox regression prediction models showed good calibration and high discriminatory performance (Harrell C statistic): cocaine-involved overdose, with (0.923) or without (0.902) an opioid; other stimulant-involved overdose, with (0.909) or without (0.868) an opioid. For cocaine-involved overdose with opioids, previous individual opioid use disorder diagnosis or cocaine use disorder diagnosis played the largest role in overdose risk prediction. For cocaine-involved overdose without opioids, previous cocaine use disorder diagnosis and area-level income inequality and housing variables contributed most to prediction. For other stimulant-involved overdose with opioids, previous opioid use disorder diagnosis and area-level percentage of those living with a disability contributed most to prediction. For other stimulant-involved overdoses without opioids, previous stimulant-related disorder and area-level proportion of individuals receiving Supplemental Nutrition Assistance Program contributed most to prediction.

CONCLUSIONS AND RELEVANCE: This case-cohort study found that readily available data can be used to identify those at high risk of hospitalization or ED visit for cocaine- or stimulant-involved overdose. These individuals would likely benefit most from evidence-based interventions and awareness of risk factors for overdose.

PMID:40971166 | DOI:10.1001/jamahealthforum.2025.3489

JAMA Netw Open. 2025 Sep 2;8(9):e2532741. doi: 10.1001/jamanetworkopen.2025.32741.

ABSTRACT

IMPORTANCE: Poverty and social disadvantage are associated with increased risks of pregnancy complications. It is not known whether poverty and social disadvantage are associated with subfertility and miscarriage risks.

OBJECTIVE: To assess whether poverty and markers of social disadvantage, including low educational level and household income among both women and men, are associated with subfertility and miscarriage risks.

DESIGN, SETTING, AND PARTICIPANTS: This population-based prospective cohort study, which was conducted in an urban setting in Rotterdam, the Netherlands, between August 9, 2017, and July 1, 2021, included women and their partners from the preconception period onward with follow-up until birth. The date of analysis was July 8, 2025.

EXPOSURES: Poverty, defined as a household income of less than €3000 per month and experiencing financial difficulties; educational level; and household income.

MAIN OUTCOMES AND MEASURES: The main outcomes were fecundability, defined as the per-month probability of conceiving; subfertility, defined as a time to pregnancy or the duration of actively pursuing pregnancy of more than 12 months or use of assisted reproductive technology; and miscarriage, defined as pregnancy loss before 22 weeks’ gestation. Data were analyzed using Cox proportional hazards regression and modified Poisson regression models.

RESULTS: Among 3604 women (median age, 31.2 [IQR, 28.5-34.3] years) and 2557 male partners (median age, 33.2 [IQR, 30.0-36.6] years), the time-to-pregnancy study population consisted of 2851 episodes among women (median age, 31.5 [IQR, 29.1-34.4] years) and 2830 episodes among men (median age, 33.3 [IQR, 30.4-36.7] years). The miscarriage study population consisted of 2515 episodes among women (median age, 31.3 [IQR, 28.8-34.1] years) and 2498 episodes among men (median age, 33.3 [IQR, 30.1-36.5] years). Among women, the median time to pregnancy was 3.5 months (95% range [2.5%-97.5%], 0-67.8 months); in total, 974 episodes (34.6%) were subfertile, and 297 pregnancy episodes (11.8%) led to a miscarriage. Subanalyses were based on 2103 to 2805 episodes among women. Poverty was associated with lower fecundability (confounder model fecundability ratio [FR], 0.61 [95% CI, 0.51-0.72]). Also, as compared with high educational level, low educational level among women (FR, 0.61 [95% CI, 0.50-0.74]) and men (FR, 0.72 [95% CI, 0.62-0.85]) was associated with lower fecundability. As compared with a household income of €6000 or more per month, a household income of less than €3000 per month was associated with lower fecundability (FR, 0.59 [95% CI, 0.51-0.68]). The effect estimates of subfertility were in line with those for fecundability; for example, poverty was associated with increased subfertility risk (32.5% vs 50.3%; relative risk, 1.37 [95% CI, 1.16-1.62]). These associations were only partly explained by demographic and lifestyle factors. Poverty and markers of social disadvantage were not associated with miscarriage risk.

CONCLUSIONS AND RELEVANCE: The findings of this cohort study suggest that poverty and social disadvantage, characterized by low educational level and household income among both women and men, were associated with lower fecundability and increased risks of subfertility but not with miscarriage risk. Further studies are needed to identify the underlying and explanatory mechanisms associated with fertility outcomes and the potential for novel public health strategies for couples desiring pregnancy.

PMID:40971155 | DOI:10.1001/jamanetworkopen.2025.32741

Clin Transplant. 2025 Sep;39(9):e70325. doi: 10.1111/ctr.70325.

ABSTRACT

BACKGROUND: Transplant is the optimal treatment for kidney failure; however, disparities in access persist. We developed and validated risk indices to predict early dropout at key stages of the transplant-seeking process not captured in national registries.

METHODS: We included patients referred for kidney transplant at Houston Methodist Hospital between June 2016, and November 2023. We collected demographic, clinical, patient- and contextual-level socioeconomic variables from electronic health records and publicly available census data. We used machine learning (ML) models to predict the characteristics of patients at higher risk of dropping out: (1) at referral (before starting evaluation), (2) in the process of evaluation (before waitlisting), and (3) during waitlisting (before receiving a transplant). Model performance was evaluated using AUROC.

RESULTS: Of 4133 referred patients, 46% did not attend their first transplant evaluation visit. Of 2414 patients who were medically eligible for transplant and started evaluation, 54% did not become waitlisted. Of 2457 waitlisted patients, 31% became inactive on the waitlist. Higher risk patients were consistently older, obese, and socioeconomically disadvantaged, with stage-specific differences: social factors-such as being single, unemployed, less educated, and living in high-deprivation areas-and African American race dominated at referral (AUROC 0.79); clinical comorbidities and both African American and Hispanic ethnicity were prominent at evaluation (AUROC 0.71); and Hispanic ethnicity, smoking, and digital exclusion were key drivers at waitlisting (AUROC 0.76).

CONCLUSION: ML models effectively identified dropout risk at referral, evaluation, and waitlisting, enabling early identification of at-risk patients. Targeted interventions could reduce disparities, improve evaluation completion, and increase transplant access.

PMID:40971151 | DOI:10.1111/ctr.70325

Am J Clin Dermatol. 2025 Sep 19. doi: 10.1007/s40257-025-00962-8. Online ahead of print.

ABSTRACT

BACKGROUND: Atopic dermatitis (AD), a chronic systemic disease, can cause intense skin itching and negatively impact sleep, mood, and quality of life (QoL) for patients and families.

METHODS: PEDISTAD is an ongoing, 10-year, observational registry describing disease characteristics, atopic comorbidities, and treatment patterns in pediatric patients (aged <12 years at enrollment) with moderate-to-severe AD. This 3-year interim analysis evaluates clinician-reported and caregiver-reported/patient-reported outcomes (Eczema Area and Severity Index [EASI], percent body surface area affected, worst itching/scratching, Children’s Dermatology Life Quality Index, and Dermatitis Family Impact) in children treated with dupilumab, methotrexate, and/or cyclosporine. Outcomes were assessed as change from therapy start to last observation (either data cutoff date or treatment discontinuation).

RESULTS: Mean (±SE) EASI scores at the time of the last 3-year interim observation were consistent with mild disease in the dupilumab cohort and moderate disease in the methotrexate and cyclosporine cohorts. Improvements in pruritus were numerically greater in the dupilumab cohort relative to the methotrexate and cyclosporine cohorts, while improvements in QoL were similar in the dupilumab and methotrexate cohorts, with no significant change in the cyclosporine cohort. Rates of AD exacerbation were numerically lower with dupilumab treatment relative to methotrexate treatment which were numerically lower than cyclosporine treatment. Dupilumab discontinuation rates were numerically lower relative to methotrexate which were numerically lower than cyclosporine.

CONCLUSIONS: This PEDISTAD 3-year interim analysis of dupilumab, methotrexate, and cyclosporine treatment in children with AD demonstrates numerically greater improvements in AD signs, symptoms and QoL with dupilumab treatment relative to methotrexate and cyclosporine [Video abstract and graphical abstract available].

CLINICAL TRIAL REGISTRATION: NCT03687359. Supplementary file1 (MP4 58163 KB).

PMID:40971133 | DOI:10.1007/s40257-025-00962-8

Ir J Med Sci. 2025 Sep 19. doi: 10.1007/s11845-025-04080-6. Online ahead of print.

ABSTRACT

OBJECTIVES: The main goal of this study was to determine the frequency of cape use among superheroes and predictors of superhero status.

DESIGN: Observational case-control study where superheroes were considered cases and villains/neutral characters controls.

SETTING: Top 25 highest grossing superhero movies.

PARTICIPANTS: Main characters in superhero movies classified as superheroes and villains through a multi-tier systems including videographic review and information collected in a superhero community database.

MAIN OUTCOME MEASURES: Frequency of different attributes between superheroes/villains (e.g., cape wearing), correlation of attributes and univariate and multivariable adjusted models of attributes associated with a superhero status.

RESULTS: There were 97 observations of 68 characters over 25 movies from three studios. There were 61 observations of superheroes and 36 villains and neutrals. Just 16% of superheroes wore capes, while 11% of non-superheroes did so. The majority (67%) of superheroes were humans, while among non-superheroes were 56%. Almost all superheroes had an altruistic mission (98%), while this attribute was present in just 19% of non-superheroes.

CONCLUSIONS: In a sample of characters from the highest grossing superhero movies, most superheroes did not wear a cape. The strongest predictor for a superhero status was having an altruistic mission.

PMID:40971124 | DOI:10.1007/s11845-025-04080-6

Ir J Med Sci. 2025 Sep 19. doi: 10.1007/s11845-025-04088-y. Online ahead of print.

ABSTRACT

BACKGROUND: Postoperative pain remains a significant concern in pediatric patients undergoing laparoscopic appendectomy. The transversalis fascia plane block (TFPB) is a recently described regional technique. In this study, we aimed to adapt this block into a laparoscopy-assisted approach and compare its analgesic efficacy with conventional wound infiltration in pediatric appendectomy.

METHODS: In this prospective, randomized controlled trial, 60 pediatric patients undergoing laparoscopic appendectomy were allocated to receive either laparoscopy-assisted TFPB (n = 30) or standard wound infiltration (WI; n = 30) with 0.25% bupivacaine (0.5 mL/kg). The primary outcome was postoperative pain evaluated via the FLACC (Face, Legs, Activity, Cry, Consolability) scale at seven time points within 24 h. Secondary outcomes included paracetamol consumption and parental satisfaction.

RESULTS: Demographic and perioperative variables were comparable between groups (p > 0.05). Paracetamol was required in significantly fewer patients in the TFPB group (36.7% vs 66.7%, p = 0.038), with fewer requiring repeated doses (13.3% vs 46.7%, p = 0.041). Although FLACC pain scores were statistically comparable between groups (p > 0.05), the TFPB group consistently showed lower median values from the fourth postoperative hour onward. Likewise, parental satisfaction was consistently high in both cohorts, with no significant variation between the analgesic techniques (p = 0.788). No adverse effects or block-related complications were reported.

CONCLUSION: Laparoscopy-assisted TFPB significantly reduced postoperative analgesic requirements compared to wound infiltration. Given its feasibility, efficacy, and safety, laparoscopy-assisted TFPB technique should be considered an alternative component of multimodal analgesia in pediatric laparoscopic abdominal surgery.

PMID:40971123 | DOI:10.1007/s11845-025-04088-y

Geroscience. 2025 Sep 19. doi: 10.1007/s11357-025-01855-8. Online ahead of print.

ABSTRACT

Rapamycin (RAPA) and related mTOR-inhibitors have been shown to enhance healthy aging in animal models (2-10) and to be generally safe and tolerable in older people (11-13). However, studies to assess their effects on specific age-related pathologies in humans are limited. Since improvements in cardiovascular function with RAPA treatment have been reported in preclinical studies (5, 9, 10, 14-17), we posited that RAPA could be similarly efficacious in humans. Towards this end, we performed a pilot “proof of concept” trial to examine RAPA’s effects on cardiovascular and endothelial functions that are known to decline with age (18, 19). We hypothesized that RAPA would elicit beneficial cardiovascular effects in men. A cohort of older male subjects with no known cardiac disease (ages 70-76 years) were enrolled in the open-label study and received 1 mg RAPA/day for 8 weeks. To assess cardiovascular function, cardiac MRI (CMR) was performed twice: prior to initiation of the intervention and again after 8 weeks of treatment. Endothelial function was examined using laser-Doppler flowmetry (LDF) by measuring cutaneous, endothelium-dependent, local thermal hyperemic responses pre-intervention and after 4 and 8 weeks of RAPA (1). In all 6 subjects, transmitral blood flow, peak flow rate, and maximal blood acceleration showed statistically significant improvements while endothelial function also improved over the 8-week course of RAPA treatment. Thus, cardiac and endothelial function improvements with RAPA were found and support future placebo-controlled studies in larger cohorts of healthy older persons as well as in patients with compromised diastolic and endothelial function (20, 21).

PMID:40971115 | DOI:10.1007/s11357-025-01855-8

Odontology. 2025 Sep 19. doi: 10.1007/s10266-025-01207-0. Online ahead of print.

ABSTRACT

Periodontitis, a chronic inflammatory disease influenced by host-microbiota interactions, poses a significant global health burden. Smoking exacerbates periodontitis progression and impacts treatment outcomes. Interleukin (IL)-17 and IL-35 are key mediators of inflammation, yet their roles in smoking-related periodontitis and responses to non-surgical periodontal treatment (NSPT) remain underexplored. This clinical trial aimed to evaluate the effects of NSPT on salivary and gingival crevicular fluid (GCF) levels of IL-17 and IL-35 in smokers and non-smokers with periodontitis. A total of 55 subjects were divided into three groups: smokers with periodontitis (SP), non-smokers with periodontitis (NSP), and healthy controls (C). All subjects underwent comprehensive periodontal assessments and cytokine level analyses at baseline and four weeks post-NSPT. Saliva and GCF samples were analysed for IL-17 and IL-35 using enzyme-linked immunosorbent assay (ELISA). Statistical analyses evaluated group differences and correlations. After NSPT, both SP and NSP groups exhibited significant improvements in clinical parameters (p < 0.05). Salivary IL-17 and IL-35 levels did not show significant differences between the SP, NSP, and C groups after NSPT (p > 0.05). However, in GCF, IL-17 and IL-35 concentrations significantly increased in both SP and NSP groups following NSPT (p < 0.05). The total amount of GCF IL-17 decreased significantly only in the NSP group after NSPT (p < 0.05), while the total amount of GCF IL-35 increased significantly in both SP and NSP groups (p < 0.05). Strong correlations between IL-17 and IL-35 levels in both saliva and GCF were observed. NSPT modulates inflammatory and anti-inflammatory cytokine profiles, promoting improved clinical outcomes. The impact of smoking on cytokine responses highlights the need for further research to elucidate the mechanisms underlying these cytokine modulations and their role in periodontal therapy. Trial registration ClinicalTrials.gov ( https://clinicaltrials.gov -01.01.2018-NCT05281848).

PMID:40971113 | DOI:10.1007/s10266-025-01207-0

Clin Oral Investig. 2025 Sep 19;29(10):467. doi: 10.1007/s00784-025-06563-3.

ABSTRACT

OBJECTIVES: The aim of this RCT was to clinically evaluate swelling, pain and wound healing following submucosal infiltration of injectable Platelet-Rich Fibrin (i-PRF) after extraction of impacted lower third molar.

MATERIALS AND METHODS: The study was designed as a double-blinded, parallel group, randomized controlled clinical trial. 56 patients were divided into 2 groups: in the control group the socket was left to heal spontaneously, while the test group was treated with submucosal infiltration of i-PRF. Swelling was measured with a flexible ruler using the diagonals joining Trago and Pogonion, Gonion and labial cleft. The swelling was calculated as the sum of these diagonals before surgery, on day 3 and 7. Pain was assessed by VAS scale until the 7th postoperative day. Surgical wound healing was evaluated by the Healing Index by Landry on 3, 7 ,14 and 21st day postosperatively. The relation between duration of intervention and total swelling was also evaluated.

RESULTS: 56 patients were enrolled in this study (28 for the test group and 28 for the control group). Randomization resulted in groups with similar baseline characteristics. No patients were lost during the follow-up and no adverse events were noted. On day 3 the total swelling was 12.7 ± 0.92 mm for control group and 12.1 ± 0.75 mm for test group; on day 7 it was 12.3 ± 0.88 mm for control group and 11.7 ± 0.73 mm for test group. A statistically significant difference was found on day 3 (p = 0.006) and on day 7 (p = 0.018). The relation between total swelling and duration of intervention was not statistically significant (p = 0.276). A significant reduction in pain scores was observed in the i-PRF group on days 1 and 3 (p < 0.001). Surgical wound healing also showed statistically significant improvement in the i-PRF group at all time points (days 3, 7, 14, and 21; p < 0.05).

CONCLUSIONS: Within the limit of our study, this randomized controlled clinical trial suggests that submucosal infiltration of i-PRF after the extraction of impacted lower third molars effectively reduces postoperative swelling and pain, while also promoting faster wound healing.

CLINICAL RELEVANCE: The adjunctive use of injectable platelet-rich fibrin (i‑PRF) after surgical removal of impacted mandibular third molars may contribute to improve early postoperative outcomes by attenuating soft tissue inflammation, reducing pain intensity, and accelerating wound healing. By potentially lowering the need for nonsteroidal anti-inflammatory drugs (NSAIDs) and minimizing associated adverse effects, i‑PRF represents a minimally invasive, autologous approach that could enhance patient comfort, reduce recovery time, and support faster return to daily activities.

PMID:40971054 | DOI:10.1007/s00784-025-06563-3