Tag: nevin manimala

JMIR Form Res. 2026 Apr 13;10:e77994. doi: 10.2196/77994.

ABSTRACT

BACKGROUND: Over 2.1 million adolescent and young adult cancer survivors (AYACS) live in the United States. Recent estimates suggest that up to one-third of AYACS experience major depressive disorder. Although several efficacious evidence-based interventions are available to manage symptoms of depression, these interventions are often inaccessible to AYACS who have many competing commitments. Digital mental health tools hold promise for this population; however, only a few have been tailored to meet the unique needs of AYACS, and findings to date have yielded mixed results.

OBJECTIVE: This study aims to obtain feedback from AYACS on a mid-fidelity prototype of a depression self-management tool being tailored for AYACS.

METHODS: Individuals with a history of cancer diagnosed at age 12 or older who were between the ages of 15 and 39 and had completed primary treatment were identified through a review of medical records from a comprehensive cancer center in the Southeastern United States. Potentially eligible participants were contacted by study staff to conduct additional screening and obtain informed consent via REDCap (Research Electronic Data Capture; Vanderbilt University). Upon enrollment, participants provided demographic and clinical information, as well as their availability for an interview. The principal investigator (KMI) conducted semistructured individual interviews with consented AYACS. Most of the interview was dedicated to showing participants the mid-fidelity prototype of the tool, explaining how the prototype might work, and requesting targeted feedback. Demographic and clinical characteristics, as well as some aspects of feedback on the prototype, were summarized using descriptive statistics. Interviews were audio- and video-recorded and transcribed. The transcriptions underwent rapid qualitative analysis guided by the Rigorous and Accelerated Data Reduction technique.

RESULTS: A total of 14 AYACS (n=9, 64%, female; n=9, 64%, white; ages 15-38) completed an individual interview. Participant preferences for mood tracking, content presentation, user input, and duration of use were captured qualitatively but analyzed quantitatively. For example, most participants (n=10, 71%) indicated that they preferred a mood-tracking option that included emojis and would be willing to track their mood at least once per day (n=11, 79%). Participant preferences captured qualitatively fell into 4 themes: (1) features to promote user engagement (eg, the use of gamification); (2) tailored content presentation (eg, authenticity in the portrayal of the cancer experience); (3) perceived usability (eg, simplifying user input); and (4) interface design (eg, implementing a coherent design theme and color scheme).

CONCLUSIONS: Findings indicated that AYACS highly value personalization, flexibility, and peer support in digital interventions. Based on insights obtained during individual interviews, a working prototype was developed by reprogramming an existing digital tool. Qualitative and quantitative findings informed modifications to the existing digital tool. The working prototype will next undergo evaluation as part of a pilot full-factorial trial.

PMID:41973497 | DOI:10.2196/77994

Ulus Travma Acil Cerrahi Derg. 2026 Apr;32(4):448-454. doi: 10.14744/tjtes.2026.88572.

ABSTRACT

BACKGROUND: Nasogastric (NG) tube decompression has traditionally been used after abdominal surgery to prevent postoperative ileus and gastric distension. The aim of this study was to evaluate the necessity of NG tube decompression following emergency repair of perforated peptic ulcer (PUP).

METHODS: This retrospective study included 189 patients who underwent emergency surgery for PUP between 1999 and 2017. Patients were divided into two groups: those managed with an NG tube (Group 1, n=154) and those managed without an NG tube (Group 2, n=35). Demographic data, clinical characteristics (American Society of Anesthesiologists [ASA] scores and comorbidities), intraoperative findings, and postoperative outcomes, including length of hospital stay, time to oral intake, and complications, were analyzed.

RESULTS: The study cohort included 189 patients, of whom 84.1% were male, with a mean age of 54.1±19.9 years. Baseline demographic and clinical characteristics, including age, comorbidities, ASA scores, and operative details, were comparable between the two groups. There were no statistically significant differences in postoperative complications or 30-day mortality. However, patients in Group 2 demonstrated a significantly earlier transition to oral feeding (3.7±0.9 vs. 4.3±1.4 days; p=0.03) and a shorter duration of hospital stay (6.6±3.1 vs. 8.1±3.8 days; p=0.04) compared to Group 1.

CONCLUSION: Routine NG decompression is not necessary following surgery for PUP. Avoiding routine NG tube use does not increase morbidity or mortality and is associated with earlier oral intake and a shorter hospital stay. We recommend the use of NG decompression in selected patients when clinically indicated.

PMID:41973493 | DOI:10.14744/tjtes.2026.88572

Ulus Travma Acil Cerrahi Derg. 2026 Apr;32(4):473-479. doi: 10.14744/tjtes.2025.08783.

ABSTRACT

BACKGROUND: The long-term outcomes of arthroscopic tenodesis using the onlay (groove) and inlay (groove) techniques remain debated with respect to tendon healing and graft stability. The aim of our study was to identify the optimal tenodesis strategy by comparing the effects of arthroscopic inlay and onlay techniques on postoperative complication rates, patient satisfaction, and functional recovery.

METHODS: Between 2015 and 2021, the treatment outcomes of 54 patients who underwent arthroscopic biceps tenodesis using either the inlay or onlay technique for the management of superior labrum anterior-to-posterior (SLAP) lesions or biceps tendon de-generation were retrospectively evaluated. Patient demographics and clinical variables, including age, sex, side of involvement, follow-up duration, visual analog scale (VAS) score, Constant score, postoperative cramping, and complications, were recorded. Group 1 consisted of 28 patients who underwent inlay tenodesis, while Group 2 included 26 patients who underwent onlay tenodesis.

RESULTS: Postoperatively, VAS scores improved substantially in both groups, with no significant difference between Group 1 (0.21±0.45) and Group 2 (0.18±0.37) (p=0.789). Similarly, postoperative Constant scores were high in both groups, with Group 1 at 92.73±8.23 and Group 2 at 95.47±5.12; this difference was not statistically significant (p=0.145). The mean recovery time was significantly shorter in Group 2 compared to Group 1. Specifically, the mean recovery time was 12.3±4.8 weeks in Group 1 and 8.3±3.72 weeks in Group 2 (p=0.01). Cramping was reported in 21.42% of patients in Group 1 and 7.69% in Group 2; however, this difference was not statistically significant (p=0.253). In Group 1, Popeye deformity developed in two patients (7.1%), whereas in Group 2 it de-veloped in one patient (3.8%).

CONCLUSION: The present study demonstrates that both inlay and onlay arthroscopic biceps tenodesis techniques are effective surgical options for managing biceps tendon degeneration and superior labrum anterior-to-posterior lesions. However, the findings suggest a potential advantage of the onlay technique, as it is associated with faster recovery and a lower risk of complications.

PMID:41973483 | DOI:10.14744/tjtes.2025.08783

Ulus Travma Acil Cerrahi Derg. 2026 Apr;32(4):480-486. doi: 10.14744/tjtes.2025.03788.

ABSTRACT

BACKGROUND: This study aimed to compare the clinical, radiological, and cost-related outcomes of early spica casting performed without anesthesia in the emergency department and spica casting performed under general anesthesia in the operating room for the treatment of femoral shaft fractures in children under five years of age.

METHODS: One hundred eleven patients who underwent closed reduction and spica casting for femoral shaft fractures between 2020 and 2024 were retrospectively reviewed. Patients were divided into two groups according to where the spica cast was applied: Emergency Department Group (ED group, n=71) and Operating Room Group (OR group, n=40). The groups were compared in terms of age, sex, fracture type, radiological alignment, and treatment costs.

RESULTS: No statistically significant differences were found between the two groups regarding age, sex, fracture pattern, or final radiological alignment. However, treatment costs were significantly lower in the emergency department group. Complication rates were also similar between the groups.

CONCLUSION: Early spica casting performed in the emergency department without general anesthesia provides radiological out-comes comparable to those achieved in the operating room while offering a significant cost advantage. With appropriate patient selec-tion, this method represents a safe and effective treatment option.

PMID:41973481 | DOI:10.14744/tjtes.2025.03788

JAMA Netw Open. 2026 Apr 1;9(4):e263171. doi: 10.1001/jamanetworkopen.2026.3171.

ABSTRACT

IMPORTANCE: Estimates of the impact of lung cancer screening (LCS) largely rely on the 3.97% lung cancer diagnosis rate (LCDR) from the National Lung Screening Trial.

OBJECTIVE: To estimate the LCDR in clinical LCS and incidental pulmonary nodule (IPN) programs.

DESIGN, SETTING, AND PARTICIPANTS: This prospective cohort study of a large regional community health care system in the Mississippi Delta included patients who had at least 1 low-dose computed tomography (CT) scan for lung cancer or any CT scan finding an IPN diameter of 30 mm or less and no prior history of lung cancer between January 1, 2015, and June 30, 2024.

EXPOSURE: Patient surveillance in LCS or IPN programs.

MAIN OUTCOMES AND MEASURES: The primary outcome was aggregate LCDRs. Secondary outcomes were relative LCDRs stratified by baseline Lung CT Screening Reporting and Data System (Lung-RADS) score (LCS cohort) or nodule size (IPN cohort). Adjusted hazard ratios (AHRs) were estimated using a Cox proportional hazards model adjusted for age, sex, race, insurance, rurality, comorbidities, personal history of non-lung cancer, and family history of lung cancer.

RESULTS: Among 40 612 patients, 15 754 were enrolled in the LCS cohort (median [IQR] age, 65 [59-69] years; 7990 male [50.7%]) and 24 858 were enrolled in the IPN cohort (median [IQR] age, 64 [52-74] years; 13 919 female [56.0%]). Among patients in the LCS cohort, 13 517 (85.8%), 994 (6.3%), 559 (3.5%), 284 (1.8%), and 179 (1.1%) had Lung-RADS scores of 1 or 2, 3, 4A, 4B, and 4X, respectively. Among patients in the IPN cohort, 9204 (37.0%) had a baseline nodule diameter of less than 6 mm, 12 872 (51.8%) had a nodule of 6 to 15 mm, 1570 (6.3%) had a nodule of greater than 15 to 20 mm, and 1212 (4.9%) had a nodule of greater than 20 to 30 mm. The cumulative LCDR at 36 months was 3.8% (95% CI, 3.4%-4.1%) and 4.3% (95% CI, 4.1%-4.6%), with a median follow-up of 546 days (IQR, 237-996 days) and 647 days (IQR, 248-1279 days), in the LCS and IPN cohorts, respectively. With Lung-RADS 1 to 2 as the reference, AHRs were 3.38 (95% CI, 2.48-4.62), 7.41 (95% CI, 5.49-49.10), 25.46 (95% CI, 19.36-33.47), and 107.22 (95% CI, 82.76-138.19) for Lung-RADS 3, 4A, 4B, and 4X, respectively, and 0.59 (95% CI, 0.44-0.79), 2.66 (95% CI, 2.23-3.18), 9.93 (95% CI, 8.06-12.22), and 15.65 (95% CI, 12.67-19.32) for nodules less than 6 mm, 6 to 15 mm, greater than 15 to 20 mm, and greater than 20 to 30 mm in the IPN cohort. Five-year overall survival was 58% (95% CI, 52%-65%) and 46% (95% CI, 43%-50%) in the LCS vs IPN cohorts.

CONCLUSIONS AND RELEVANCE: In this cohort study of LCS and IPN program patients, approximately 4% were diagnosed with lung cancer over less than half the duration of the NLST cohort, suggesting a greater population-level LCDR through these screening programs than estimated by clinical trial data.

PMID:41973426 | DOI:10.1001/jamanetworkopen.2026.3171

JAMA Netw Open. 2026 Apr 1;9(4):e265177. doi: 10.1001/jamanetworkopen.2026.5177.

ABSTRACT

IMPORTANCE: Guidelines recommend tailored (ie, individualized) exercise strategies for cancer survivors. However, there are limited data on the effects of these strategies on long-term mortality outcomes among breast cancer survivors.

OBJECTIVE: To estimate the effect of tailored exercise strategies on mortality for breast cancer survivors.

DESIGN, SETTING, AND PARTICIPANTS: In this cohort study, a target trial protocol was first specified to approximately mirror the Colon Health and Lifelong Exercise Change (CHALLENGE) trial among breast cancer survivors. Observational data from the Pathways Study were used to emulate this first target trial. These results were then extended by emulating a second target trial of more pragmatic, tailored exercise strategies applied to a broader population of breast cancer survivors. Women enrolled in the Kaiser Permanente Northern California health plan were recruited from January 2006 to December 2013, and were followed up through December 2021. Analyses were performed between September 2024 and September 2025.

EXPOSURES: Tailored exercise strategies adaptively modified based on evolving characteristics.

MAIN OUTCOMES AND MEASURES: All-cause and breast cancer-specific mortality.

RESULTS: In the first target trial, there were 959 eligible women (mean [SD] age, 58.3 [12.5] years) and 183 deaths. Compared with a strategy similar to the health education intervention of the CHALLENGE trial, an aerobic exercise strategy was associated with an 8.0 (95% CI, 3.4-13.3)-percentage point lower 8-year all-cause mortality risk, which was compatible with the CHALLENGE trial (7.1 [95% CI, 1.8-12.3]-percentage point lower risk). In the second target trial, there were 2107 eligible women (mean [SD] age, 60.1 [12.1] years) and 321 deaths. Estimated 10-year all-cause mortality ranged from 18.1% to 21.2%. Breast cancer-specific mortality ranged from 7.6% to 10.0%. Compared with no intervention, engaging in a tailored strategy requiring an increase of 60 minutes of vigorous or 120 minutes of moderate aerobic exercise per week was associated with a 3.1 (95% CI, 2.0-4.6)-percentage point lower 10-year all-cause mortality risk and a 2.4 (95% CI, 1.2-3.5)-percentage point lower 10-year breast cancer-specific mortality risk.

CONCLUSIONS AND RELEVANCE: In this cohort study using a target trial emulation design, tailored exercise strategies were associated with reductions in 10-year mortality among breast cancer survivors. A randomized trial is warranted to confirm these findings.

PMID:41973424 | DOI:10.1001/jamanetworkopen.2026.5177

JAMA Netw Open. 2026 Apr 1;9(4):e266100. doi: 10.1001/jamanetworkopen.2026.6100.

ABSTRACT

IMPORTANCE: Familial hypercholesterolemia is a common genetic disorder associated with premature cardiovascular disease. Genetic cascade screening is recommended but remains underused due to privacy laws that prevent clinicians from directly contacting at-risk relatives.

OBJECTIVE: To examine whether implementing a web-based communication platform in a patient-mediated genetic cascade screening program for familial hypercholesterolemia increases uptake compared with usual care.

DESIGN, SETTING, AND PARTICIPANTS: This open-label, multicenter, implementation randomized clinical trial (CATCH) was conducted between November 1, 2020, and October 31, 2023, at 7 cardiovascular prevention or lipid clinics across Switzerland, representing French-, German-, and Italian-speaking regions. Adults aged 16 years or older with genetically confirmed familial hypercholesterolemia and at least 1 eligible first-degree relative living in Switzerland participated. A total of 87 index patients with 359 eligible first-degree relatives were randomized by family cluster (1:1) to the intervention or usual care arm.

INTERVENTION: A secure web-based platform allowing participants to send preprepared electronic messages (email or text) to their relatives, linking them directly to participating centers for genetic testing.

MAIN OUTCOMES AND MEASURES: The primary outcome was cascade screening uptake, defined as the proportion of eligible first-degree relatives undergoing genetic testing within 6 months. The secondary outcome was new cases identified.

RESULTS: Among 221 adults screened across multiple families, 87 (39.4%) had genetically confirmed familia hypercholesterolemia (median [IQR] age, 49.2 [16.4-83.7] years; 46 [52.9%] female; median [IQR] highest low-density lipoprotein cholesterol, 289.58 [139.00-498.07] mg/dL); 43 were randomized to the usual care arm, and 44 were randomized to the intervention arm. Among the 359 eligible relatives (median family size, 4), 99 (27.6%) underwent genetic testing. Uptake was higher in the intervention arm (30.4%; 95% CI, 22.0%-40.4%) than in usual care arm (16.7%; 95% CI, 10.1%-26.3%), yielding an odds ratio of 2.18 (95% CI, 1.06-4.51; P = .03). New case identification was also greater (17.0% vs 8.1%; odds ratio, 2.32; 95% CI, 1.07-5.05; P = .03). Newly identified patients were often untreated or had modifiable risk factors.

CONCLUSIONS AND RELEVANCE: In this randomized clinical trial of patient-mediated genetic cascade screening supported by a web-based platform, participation in genetic testing and detection of familial hypercholesterolemia was increased compared with usual care. These results suggest that the use of digital communication tools enhanced the reach and effectiveness of genetic screening programs within privacy-regulated health systems.

TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04419090.

PMID:41973423 | DOI:10.1001/jamanetworkopen.2026.6100

JAMA Netw Open. 2026 Apr 1;9(4):e266458. doi: 10.1001/jamanetworkopen.2026.6458.

ABSTRACT

IMPORTANCE: Patients with sickle cell disease (SCD) may experience clinician biases due to intersecting stigmatizing factors because most patients with SCD racially identify as Black, have pain as the most common presenting symptom, and are often treated with opioids.

OBJECTIVE: To examine intersecting stigmatizing identities of patients with SCD-identifying as Black, presenting with pain, and being treated with opioids-and compare differences in negative descriptors in the electronic health record relative to SCD.

DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional, single-center study of outpatient, emergency department, and inpatient encounters examined clinician notes from January 1, 2019, to October 1, 2020. Clinician notes were included for patients who racially identified as Black or had diagnoses of SCD, chronic pain, or opioid use disorder (OUD). Notes were also included for a counterfactual group of patients who were not Black and did not have SCD, chronic pain, or OUD. Data were analyzed from November 2024 to February 2026.

EXPOSURE: Patients with SCD were compared with 4 groups, all without SCD: (1) Black patients, (2) patients with chronic pain, (3) patients with OUD, and (4) the counterfactual group.

MAIN OUTCOMES AND MEASURES: Using natural language processing and a machine learning model, clinician notes were contextually coded for the application of 7 negative descriptors: aggressive, agitated, angry, nonadherent, noncompliant, noncooperative, and refuse.

RESULTS: A total of 39 871 clinician notes across 18 326 patients were analyzed (mean [SD] age, 47 [23] years); 2183 patients were pediatric (12%), 10 243 were female (56%), 11 137 were Black (63%), 5907 were married (32%), and 5884 had Medicaid (32%). Negative descriptors were present in 220 of 1443 notes (15%) among patients with SCD and 124 of 643 notes (19%) among those with all 4 stigmatizing identities. There were higher odds of a negative descriptor in notes about patients with SCD compared with Black patients without SCD (aOR, 2.46; 95% CI, 1.62-3.73), patients with chronic pain without SCD (aOR, 1.96; 95% CI, 1.18-3.27), and patients in the counterfactual group (aOR, 14.26; 95% CI, 5.92-34.36), but there was no difference compared with patients with OUD without SCD (aOR, 0.76; 95% CI, 0.42-1.38).

CONCLUSIONS AND RELEVANCE: In this cross-sectional study of 18 326 patients, those with SCD had more negative descriptors than Black patients without SCD or those with chronic pain but at a similar level as those with OUD.

PMID:41973422 | DOI:10.1001/jamanetworkopen.2026.6458

JAMA Netw Open. 2026 Apr 1;9(4):e266571. doi: 10.1001/jamanetworkopen.2026.6571.

ABSTRACT

IMPORTANCE: Psychiatric disorders are a major global public health concern, highlighting the urgent need for policies to mitigate their impact, especially for at-risk populations.

OBJECTIVE: To investigate the association of the Brazilian conditional cash transfer program (Bolsa Familia Program [BFP]) with psychiatric disorder hospitalizations and availability of community mental health service.

DESIGN, SETTING, AND PARTICIPANTS: This cohort study was conducted during an 8-year period using linked social and health data from the 100 Million Brazilian Cohort. The participants were all individuals who were registered at CadÚnico between January 1, 2008, and December 31, 2015. Statistical analyses were conducted between August 12, 2025, and January 31, 2026.

EXPOSURE: Participation in the BFP.

MAIN OUTCOMES AND MEASURES: All psychiatric disorder hospitalizations registered on the Hospital Information System according to International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) as psychiatric disorders, except for substance use disorders.

RESULTS: A total of 38 572 143 individuals (mean [SD] age, 21.66 [22.06] years; 20 661 009 [54%] female and 17 911 134 [44%] male; 188 033 [0.49%] Asian, 2 238 344 [5.80%] Black, 280 859 [0.73%] Indigenous, 22 123 435 [57.36%] Pardo [includes individuals with Black or mixed ancestry, including European, African, and Indigenous heritage], and 12 749 758 [33.05%] White) were included in the analysis. A total of 56 646 individuals (0.1%) had a psychiatric disorder hospitalization during the study period. Individuals who received a cash transfer from the BFP had a 23% lower risk of psychiatric disorders hospitalization (hazard ratio [HR], 0.77; 95% CI, 0.76-0.79). The association was stronger among Pardo (HR, 0.72; 95% CI, 0.69-0.74) and Black (HR, 0.78; 95% CI, 0.72-0.85) individuals who lived in the poorest municipalities (HR, 0.67; 95% CI, 0.63-0.71) regardless community mental health care.

CONCLUSIONS AND RELEVANCE: In this cohort study of the 100 Million Brazilian Cohort, a national cash transfer program was associated with lower risk of psychiatric hospitalizations, especially among at-risk populations who experience health inequalities.

PMID:41973421 | DOI:10.1001/jamanetworkopen.2026.6571

JAMA Netw Open. 2026 Apr 1;9(4):e266771. doi: 10.1001/jamanetworkopen.2026.6771.

ABSTRACT

IMPORTANCE: Syphilis, which is caused by Treponema pallidum, has historically been associated with cardiovascular complications. Despite a resurgence of syphilis incidence in the US, large-scale studies evaluating its independent cardiovascular impact are lacking.

OBJECTIVE: To determine whether syphilis infection is independently associated with increased risk of adverse cardiovascular outcomes in a US health system population.

DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study with a 15-year follow-up (January 1, 2011, to July 1, 2025) was performed within a tertiary health care system in New Orleans, Louisiana. Participants included adults with syphilis identified using codes from the International and Statistical Classification of Diseases, Tenth Revision (ICD-10) and controls without syphilis who were matched based on demographic characteristics and comorbidities. Patients with preexisting cardiovascular disease were excluded. Data were analyzed from January 1, 2011, to July 1, 2025.

EXPOSURES: Diagnosis of syphilis (primary, secondary, tertiary, or unspecified stage) documented by ICD-10 codes.

MAIN OUTCOMES AND MEASURES: Incident cardiovascular events included myocardial infarction, heart failure, aortic regurgitation, atrial fibrillation, aortic aneurysm or dissection, ischemic stroke, hemorrhagic stroke, peripheral artery disease, venous thromboembolism, and death. Outcomes were assessed using Kaplan-Meier survival curves and were adjusted for body mass index.

RESULTS: A total of 8814 participants were included in the analysis (4753 [53.9%] female; mean [SD] age, 50.0 [17.0] years). The syphilis group (n = 1469) and control group (n = 7345) were similar in terms of their demographic characteristics (mean [SD] age, 50.1 [17.0] vs 50.0 [17.6] years [P = .78]; 795 [54.1%] vs 3958 [53.9%] female [P = .84]) and comorbidities. In adjusted analyses, syphilis was associated with an increased risk of aortic aneurysm or dissection (hazard ratio [HR], 2.08; 95% CI, 1.47-2.94; P = .001), ischemic stroke (HR, 1.53; 95% CI, 1.27-1.84; P < .001), hemorrhagic stroke (HR, 1.92; 95% CI, 1.23-2.99; P = .004), peripheral artery disease (HR, 1.28; 95% CI, 1.01-1.62; P = .04), death (HR, 5.80; 95% CI, 3.81-8.82; P < .001), and myocardial infarction (HR, 1.33; 95% CI, 1.06-1.67; P = .01). No associations were found for heart failure (HR, 0.98; 95% CI, 0.83-1.17), atrial fibrillation (HR, 0.85; 95% CI, 0.67-1.08), aortic regurgitation (HR, 1.58; 95% CI, 0.87-2.87), or venous thromboembolism (HR, 1.47; 95% CI, 0.76-2.94).

CONCLUSIONS AND RELEVANCE: In this retrospective cohort study of adults with syphilis, infection was independently associated with higher risk of several major cardiovascular outcomes. These findings underscore the importance of early detection and treatment of syphilis and suggest a role for incorporating cardiovascular risk assessment into comprehensive syphilis management strategies.

PMID:41973418 | DOI:10.1001/jamanetworkopen.2026.6771