Tag: statistics

JMIR Form Res. 2026 Jul 8;10:e88916. doi: 10.2196/88916.

ABSTRACT

BACKGROUND: Crown preparation is a technically demanding psychomotor skill in undergraduate dental education. While traditional typodont training is the gold standard, it is resource-intensive and difficult to individualize. Screen-based haptic virtual reality simulators (HVRSs) may provide a pedagogical adjunct to conventional training, but their effectiveness in supporting transfer of skills to physical tooth preparation remains unclear.

OBJECTIVE: This study evaluated whether 3 hours of self-directed HVRS training improved undergraduate dental students’ performance in physical typodont crown preparation compared with no HVRS training. Secondary aims were to examine self-confidence and students’ perceptions of HVRS-based training. Manual dexterity was assessed exploratorily using the Grooved Pegboard Test (GPT).

METHODS: A mixed methods study was conducted with 44 fifth-semester dental students at Karolinska Institutet. Participants were allocated to an HVRS training group (n=22) or a control group (n=22). The HVRS group completed 3 hours of self-directed HVRS training over 1 week, whereas the control group received no simulator-based training. Both groups then prepared a maxillary right first molar for a monolithic zirconia crown on a phantom head. Crown preparation quality was assessed using PrepCheck, and a blinded examiner scored 8 areas of interest on a 0-3 grading scale. Manual dexterity was assessed using the GPT. Self-confidence was evaluated in both groups using survey items, while perceptions of the HVRS were evaluated only among HVRS group participants. Free-text responses from the HVRS group were analyzed using inductive thematic analysis.

RESULTS: The HVRS group achieved a higher mean total preparation score than the control group, but the difference was not statistically significant (11.9 vs 10.9; P=.24). In unadjusted analyses, the HVRS group scored higher for total occlusal convergence (P=.04), but this difference did not remain statistically significant after Bonferroni correction for 8 area-of-interest comparisons. Manual dexterity measured by the GPT improved in both groups, but the control group was significantly faster at baseline (P=.04) and postintervention (P=.001). Self-confidence ratings were broadly similar between groups; very low confidence was reported by 5% (1/20) of respondents in the HVRS group and 18% (4/22) in the control group. Most HVRS group respondents rated the HVRS drilling sensation as having limited comparability with typodont teeth and natural teeth. Qualitative responses suggested that students valued the HVRS for understanding procedural steps, applying theoretical knowledge, and allowing repeated practice, while reported challenges included limited realism, visual-tactile disconnect, and occasional technical issues.

CONCLUSIONS: Three hours of self-directed HVRS training did not significantly enhance overall crown preparation quality on typodont teeth or improve students’ general self-confidence. There is preliminary indication that HVRS could assist in mastering specific geometric parameters like total occlusal convergence. Future randomized controlled trials with stratified baseline dexterity and larger sample sizes are required to determine the optimal role of HVRS in dental education.

PMID:42418261 | DOI:10.2196/88916

J Biochem Mol Toxicol. 2026 Jul;40(7):e71018. doi: 10.1002/jbt.71018.

ABSTRACT

This study aimed to investigate the biological effects of Picroside II on colorectal cancer (CRC) cells, including its impacts on proliferation, migration, invasion, and epithelial-mesenchymal transition (EMT), and to explore whether its mechanism of action involves modulation of the Notch1 signaling pathway. Human CRC cell lines SW480 and SW620 were treated with various concentrations of Picroside II (10-100 μM). Cell proliferation was assessed using the CCK-8 assay, colony formation assay, and EdU incorporation assay. Migration and invasion capacities were evaluated by wound healing and Transwell assays. The expression levels of EMT-related markers (E-cadherin, N-cadherin, Vimentin, ZEB2) and key proteins in the Notch1 pathway (Notch1, Cleaved Notch1, RBP, HES1) were analyzed by Western blotting. Statistical analysis was performed using one-way ANOVA and Student’s t-test. Picroside II inhibited the proliferation of SW480 and SW620 cells in a dose- and time-dependent manner, reduced colony formation ability, and decreased DNA synthesis activity. Treatment with Picroside II suppressed the migratory and invasive abilities of CRC cells, accompanied by upregulation of E-cadherin and downregulation of N-cadherin, Vimentin, and ZEB2. Furthermore, Picroside II exposure led to a decrease in the expression of Notch1, Cleaved Notch1, RBP, and HES1 proteins in a concentration-dependent manner. Picroside II suppresses CRC cell progression in vitro by inhibiting the Notch1 signaling pathway, providing a preliminary molecular basis for further in vivo investigation.

PMID:42418248 | DOI:10.1002/jbt.71018

JMIR Med Educ. 2026 Jul 8;12:e82812. doi: 10.2196/82812.

ABSTRACT

BACKGROUND: Taiwan is projected to become a “super-aged” society by 2025, leading to an increasing demand for community psychiatric long-term care (LTC). This demographic shift necessitates frontline professionals equipped with specialized communication skills and deep empathy. However, traditional didactic teaching often fails to adequately prepare students for the complex emotional and practical challenges of real-world psychiatric caregiving.

OBJECTIVE: This study aimed to evaluate the effectiveness of the innovative youth-elder co-learning instructional model, which uniquely integrates micro-movie discussions and an intergenerational empathy board game, on adult learners’ professional knowledge, communication competence, empathic development, and overall learning satisfaction.

METHODS: A mixed methods, single-group, pre-post design was used. The educational intervention was implemented within an 18-week elective community psychiatric LTC course. Participants included 38 adult learners and continuing education students (aged 19-64 years). Notably, the majority of the cohort (n=29, 76.3%) had no prior practical experience in LTC. Quantitative data were collected using self-assessed and peer-evaluated scales for professional knowledge, communication competence, and empathy at pre-, mid-, and post-course time points, alongside an end-of-semester course student feedback survey. Qualitative data were systematically gathered through structured reflective journals and analyzed using a rigorous 6-phase thematic analysis framework.

RESULTS: Students reported high course satisfaction rates, ranging from 92.4% to 95.3%. Quantitative analysis revealed a notable divergence: there were significant improvements in peer-evaluated outcomes (P<.001) and self-assessed communication competence (P=.004), but there was more conservative, statistically nonsignificant growth in self-assessed scores for professional knowledge (P=.14) and empathy (P=.09). This discrepancy likely reflects adult learners’ heightened awareness of professional complexity and self-reflective humility. Furthermore, the qualitative thematic analysis uncovered the following three narrative shifts: (1) the dismantling of generational stereotypes through authentic, face-to-face interaction with real older adults; (2) an empathic awakening regarding the often-invisible burden of family caregivers, catalyzed by the micro-movies; and (3) the successful translation of theoretical nonviolent communication concepts into real-time clinical problem-solving during board game role-plays.

CONCLUSIONS: The youth-elder co-learning model shows promise as an innovative, experiential pedagogical approach. By bridging theoretical frameworks with authentic intergenerational contact, the intervention supported students in translating general empathic concepts into actionable communication competencies. However, given the exploratory nature of this study and the absence of a control group, the quantitative findings must be interpreted cautiously. Future research using randomized controlled trial designs across multiple institutions is warranted to establish definitive causal impacts.

PMID:42418241 | DOI:10.2196/82812

J Med Internet Res. 2026 Jul 8;28:e95944. doi: 10.2196/95944.

ABSTRACT

BACKGROUND: Sexually transmitted infections (STIs) are at a record high in the United States and are a significant health problem for childbearing women. Rates of substance use, particularly cannabis and opioid use, have increased in recent years and are linked to negative health consequences for pregnant women and their infants. Addressing these health concerns together during this vulnerable time is a priority.

OBJECTIVE: This study aims to test whether the Health Check-Up for Expectant Moms (HCEM), an innovative, theory-driven, technology-delivered, and fully automated brief intervention, reduced condomless sex and STI risk, alcohol, or drug use, compared to a control condition in pregnant women seeking prenatal care.

METHODS: We recruited a sample of 176 pregnant women (all were at risk for alcohol or drug use or STIs during pregnancy) from clinics and using social media campaigns (Facebook and Instagram) in the state of Michigan and randomized them to the motivational interviewing-consistent HCEM intervention or to an attention-, time-, and information-matched control condition delivered using the same technology platform. We followed these women at 2 and 6 months after the initial intervention visit. Primary outcomes included self-report assessment of alcohol, drug, or cannabis use and unprotected sexual occasions during pregnancy.

RESULTS: A total of 88 women were randomized to the intervention, and 88 to the control condition. Cannabis use was the most prevalent substance reported during pregnancy; a total of 35.2% (62/176) reported recent use (within the last 90 days) at baseline, with 10.2% (18/176) reporting use in the month prior to baseline. There were significant reductions in alcohol and cannabis use over time during pregnancy (at 2 and 6 months compared to baseline) in both HCEM and control groups; however, these reductions were not significantly different between conditions (time-by-arm interaction), and most were sustained from spontaneous reductions reported in the month before study enrollment. Moreover, there were no statistically significant differences in the change pattern of condomless sex across the groups at either follow-up.

CONCLUSIONS: There are many potential benefits of a technology-delivered approach to support the behavioral health of pregnant women in a private and convenient way. Our sample was largely low-risk, and as such, an intervention effect may have been impossible to observe given substantial self-change. Future trials are needed to examine efficacy in other samples of pregnant women with a higher risk of current alcohol or drug use.

TRIAL REGISTRATION: ClinicalTrials.gov NCT03826342; https://clinicaltrials.gov/study/NCT03826342.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/30367.

PMID:42418232 | DOI:10.2196/95944

J Public Health Dent. 2026 Jul 8. doi: 10.1111/jphd.70067. Online ahead of print.

ABSTRACT

OBJECTIVE: This retrospective cohort study determined associations between Medicaid reimbursement policies for silver diamine fluoride treatment (SDF) and utilization.

METHODS: Data included publicly available Medicaid provider manuals and fee schedules as well as aggregated claims from CareQuest Institute for Oral Health. The main outcome was SDF utilization rate calculated as a percentage of claims per enrollees. Summary statistics and linear mixed models with random intercepts were applied.

RESULTS: Fourteen states were included in the analysis. The median SDF utilization rate across states increased from 1.80% (IQR: 1.37%, 2.59%) in 2018 to 3.35% (IQR: 1.94%, 5.54%) in 2022. Of seven potential policy dimensions, only reimbursement amount was significantly associated with SDF utilization rate, and only when accounting for time (β = 0.15; 95% CI: 0.12, 0.18).

CONCLUSION: Policy factors, particularly reimbursement amount, likely play a role in SDF utilization; however, additional research is needed to understand how dentists adopt SDF in ways that translate into improved outcomes.

PMID:42418227 | DOI:10.1111/jphd.70067

J Appl Clin Med Phys. 2026 Jul;27(7):e70689. doi: 10.1002/acm2.70689.

ABSTRACT

BACKGROUND: Whole-brain radiotherapy (WBRT) is a common treatment due to its simplicity and effectiveness. While automated Field-in-Field (Auto-FiF) functions assist WBRT planning in modern treatment planning systems, it still requires manual approaches for optimal plan generation including patient-specific hyperparameters definition and plan refinement based on quality feedback.

PURPOSE: This study introduces an automated WBRT planning pipeline that integrates a deep learning (DL) Hyperparameter Prediction model for patient-specific parameter generation and a large-language model (LLM)-based conversational interface for interactive plan refinement.

METHODS: The Hyperparameter Prediction module was trained on 55 WBRT cases using geometric features of clinical target volume (CTV) and organs at risk (OARs) to determine optimal Auto-FiF settings in RayStation treatment planning system. Plans were generated under predicted hyperparameters. For cases in which the generated plan was suboptimal, quality feedback via voice input was captured by a Conversation module, transcribed using Whisper, and interpreted by GPT-4o to adjust planning settings. Plan quality was evaluated in 15 independent cases using clinical metrics and expert review, and model explainability was supported through analysis of feature importance.

RESULTS: Fourteen of 15 DL-generated plans were clinically acceptable. Normalized to identical CTV D95% as the clinical plans, the DL-generated and clinical plans showed no statistically significant differences in doses to the eyes, lenses, or CTV dose metrics D1% and D99%. The DL-based planning required under 1 min of computation and achieved total workflow execution in approximately 7 min with a single mouse click, compared to 15 min for manual planning. In cases requiring adjustment, the Conversational module successfully improved dose conformity and hotspot reduction.

CONCLUSIONS: The proposed system improves planning efficiency while maintaining clinically acceptable plan quality. It demonstrates the feasibility of combining DL-based hyperparameter prediction with LLM interaction for streamlined, high-quality WBRT planning.

PMID:42418216 | DOI:10.1002/acm2.70689

JAMA Netw Open. 2026 Jul 1;9(7):e2621262. doi: 10.1001/jamanetworkopen.2026.21262.

ABSTRACT

IMPORTANCE: Intermittent theta-burst stimulation (iTBS) is an established treatment for major depressive disorder (MDD), but sham-controlled evidence for once-daily protocols remains limited.

OBJECTIVE: To determine whether 10 sessions of once-daily iTBS is superior to sham iTBS for adults with MDD.

DESIGN, SETTING, AND PARTICIPANTS: This randomized clinical trial was conducted at an outpatient psychiatric clinic in North Norway between January 1, 2022, and June 30, 2025, among 73 patients with MDD, aged 22 to 65 years, with a Montogomery-Åsberg Depression Rating Scale (MADRS) score of 20 or more, regardless of treatment refractoriness level. Statistical analyses were completed in October 2025.

INTERVENTION: Participants were randomized to 10 weekday sessions of once-daily iTBS (600 pulses at 120% of the resting motor threshold) or sham stimulation delivered with a validated sham coil to the left dorsolateral prefrontal cortex. A 4-week follow-up evaluated sustained effects.

MAIN OUTCOMES AND MEASURES: Main outcomes were between-group differences in depression scores on day 10, measured with the clinician-rated MADRS and the Beck Depression Inventory-II (BDI-II). Secondary outcomes included MADRS scores on day 5, MADRS and BDI-II scores at follow-up, and response and remission rates on day 10. Repeated depression measures were analyzed using linear mixed-effects models in a modified intention-to-treat sample. Adverse events were assessed daily and compared between groups.

RESULTS: Seventy-three participants (mean [SD] age, 36.1 [10.6] years, 40 female [54.8%]) completed the study: 41 were randomized to active iTBS and 32 to sham. iTBS was superior to sham on day 10 for MADRS scores (mean difference, 3.57 [95% CI, 0.79-6.35]; Hedges g = 0.61; P = .01), but not for BDI-II scores (mean difference, 3.05 [95% CI, -2.72 to 8.82]; P = .30). iTBS was also superior to sham on day 5 for MADRS scores (mean difference, 2.89 [95% CI, 0.13-5.64]; Hedges g = 0.50; P = .04) but not significant at follow-up due to improvement in the sham group. Treatments were well tolerated, with mild and transient adverse events.

CONCLUSIONS AND RELEVANCE: In this randomized clinical trial of adults with MDD, a fixed 10-session schedule of once-daily iTBS resulted in greater reductions in clinician-rated depressive symptoms than sham during the treatment phase. The group difference was not sustained at the 4-week follow-up. These findings highlight the importance of treatment duration and extended follow-up in interpreting clinical response.

TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT05516095.

PMID:42418203 | DOI:10.1001/jamanetworkopen.2026.21262

JAMA Netw Open. 2026 Jul 1;9(7):e2621705. doi: 10.1001/jamanetworkopen.2026.21705.

ABSTRACT

IMPORTANCE: Invasive lobular carcinoma (ILC) represents the second most common histologic subtype of breast cancer (BC), yet its genomic landscape and clinical implications remain less well defined compared with invasive ductal carcinoma. Understanding genetic predisposition in ILC may improve risk assessment and guide tailored clinical management.

OBJECTIVES: To investigate the prevalence and clinical outcomes of germline pathogenic or likely pathogenic variants (PVs) in BC predisposition genes among women with ILC and to assess the prognostic utility of polygenic risk scores (PRSs) in this population.

DESIGN, SETTING, AND PARTICIPANTS: This prospective, longitudinal cohort study was conducted at the European Institute of Oncology, Milan, Italy, from May 16, 2022, to January 31, 2025. Women diagnosed with primary ILC were enrolled and underwent multigene panel testing of 113 genes using next-generation sequencing. Follow-up data were collected until January 31, 2023. Statistical analysis was performed in January 2026.

MAIN OUTCOMES AND MEASURES: The primary outcome was BC-free survival, defined as the time from surgery to ipsilateral recurrence, contralateral disease, distant metastasis, or BC-related death. Secondary outcomes included overall survival and PRS distribution across genetic subgroups.

RESULTS: A total of 414 White women (mean [SD] age, 53.7 [9.7] years; 211 [51.0%] with postmenopausal status) with ILC were tested. No significant associations were found between germline variant subgroups and patients’ characteristics. PVs were identified in 46 patients (11.1%), with 20 (4.8%) carrying variants in moderate- to high-risk BC genes (ATM, BARD1, BRCA1, BRCA2, CDH1, CHEK2, NF1, FANCM, PALB2, RAD51C, RAD51D, STK11, TP53, and PTEN). The group of women carrying PVs in moderate- to high-risk BC genes had significantly reduced 5-year BC-free survival compared with the rest of cohort (62.2% [95% CI, 32.3%-82.0%] vs 92.1% [95% CI, 87.6%-95.0%]; hazard ratio, 3.91; 95% CI, 1.99-7.67; P < .001). PRS analysis did not reveal statistically significant differences in relapse risk across quartiles of PRS, and no association was found between PRSs and germline variant status.

CONCLUSIONS AND RELEVANCE: This cohort study of women with primary ILC identified a clinically relevant subset of patients carrying moderate- to high-risk germline PVs who exhibited an increased risk of early relapse. Although PRSs did not show prognostic value in this setting, multigene panel testing findings may refine genetic counseling and inform surveillance and therapeutic strategies in lobular breast tumors.

PMID:42418202 | DOI:10.1001/jamanetworkopen.2026.21705

JAMA Netw Open. 2026 Jul 1;9(7):e2622218. doi: 10.1001/jamanetworkopen.2026.22218.

ABSTRACT

IMPORTANCE: Infants classified as small or large for gestational age can have different growth patterns compared with appropriate-for-gestational age counterparts. The association of birth weight percentiles beyond conventional thresholds with early-life growth remains unknown.

OBJECTIVE: To quantify the association of birth weight percentile range with infant and child growth.

DESIGN, SETTING, AND PARTICIPANTS: This is a prospective cohort study of singletons born between 1991 and 2011 in 7 birth cohort studies in Europe, Singapore, and the US and followed up with repeated growth measurements for 10 years. Five European cohorts were used for discovery analysis, and the Singapore and US cohorts were used for replication analyses.

EXPOSURES: Birth weight percentiles standardized for sex and gestational age using the INTERGROWTH-21st standards and classified into 10 decile groups, with the middle (fifth and sixth decile groups) as the reference group.

MAIN OUTCOMES AND MEASURES: The primary outcomes were infant height (centimeters per month) and weight (grams per month) growth velocity at 1, 6, 12, 24 months; body mass index (BMI; calculated as weight in kilograms divided by height in meters squared); age (months or years) at infant BMI peak and childhood BMI rebound; and overweight or obesity at 10 years. Associations were examined using regression models adjusted for sex and birth cohort.

RESULTS: The discovery cohort included 36 018 children (mean [SD] gestational age at birth, 39.7 [1.8] weeks; 17 238 girls [48%]). Compared with the reference group, higher decile groups had lower early infant height velocity that reversed by 24 months, higher weight velocity from 6 to 24 months, higher and earlier peak BMI, higher rebound BMI, and increased risk of overweight or obesity at age 10 years. Lower decile groups showed the opposite patterns. For example, mean differences for infant peak BMI were -0.38 (95% CI, -0.43 to -0.33) for the second decile birth weight group and 0.33 (95% CI, 0.29 to 0.38) for the ninth decile birth weight group compared with the fifth to sixth decile birth weight group. Mean differences for age at peak BMI were 0.22 months (95% CI, 0.12 to 0.33 months) for the second decile birth weight group and -0.21 months (95% CI, -0.30 to -0.11 months) for the ninth decile birth weight group compared with the fifth to sixth decile birth weight groups. Risk ratios for overweight or obesity at 10 years were 0.86 (95% CI, 0.76 to 0.97) for the second decile birth weight group and 1.25 (95% CI, 1.13 to 1.38) for the ninth decile birth weight group. Birth weight was not associated with age at rebound BMI. Replication analyses (2517 children; mean [SD] gestational age at birth, 39.2 [1.8] weeks; 1191 girls [47%]) supported these findings. Associations were typically linear and similar in boys and girls. Deciles provided only modest estimation gains over conventional categories.

CONCLUSIONS AND RELEVANCE: In this cohort study of 38 535 singletons, birth weight decile was associated with early-life growth patterns. Birth weight decile group may help identify high-risk children missed by conventional thresholds, although the benefit of analysis using decile group over traditional groups remains modest.

PMID:42418198 | DOI:10.1001/jamanetworkopen.2026.22218

JAMA Surg. 2026 Jul 8. doi: 10.1001/jamasurg.2026.2516. Online ahead of print.

ABSTRACT

IMPORTANCE: Preoperative localization is often required to achieve successful sublobar resection with adequate margins for computed tomography (CT)-detected pulmonary nodules suspicious for early-stage lung cancer. Conventional CT-guided localization involves a multiple-encounter workflow that may cause pain, radiation exposure, and complications.

OBJECTIVE: To determine whether a single-encounter augmented reality (AR)-guided percutaneous localization strategy is noninferior to standard multiple-encounter CT-guided localization for achieving successful sublobar resection.

DESIGN, SETTING, AND PARTICIPANTS: This randomized noninferiority trial was conducted at 5 centers in China between August 8, 2024, and September 30, 2025. Among 296 randomized patients, 270 were included in the modified intention-to-treat analysis (134 in AR; 136 in CT). Exclusion criteria included multiple nodules (≥2), unsafe percutaneous access, comorbidities limiting participation, or consent withdrawal.

INTERVENTIONS: Single-encounter AR-guided percutaneous localization performed in the operating room under general anesthesia vs multiple-encounter CT-guided percutaneous localization performed in the CT suite under local anesthesia followed by transfer to the operating room for surgery.

MAIN OUTCOMES AND MEASURES: The primary outcome was successful sublobar resection, defined as R0 resection with protocol-defined margin adequacy according to nodule type. Secondary outcomes included localization accuracy, radiation exposure, complications, patient-reported outcomes, and procedural efficiency.

RESULTS: The median (IQR) age of the population was 59 (50-67) years, and 172 participants (63.7%) were female. Successful sublobar resection occurred in 132 of 134 AR-guided procedures (98.5%) and 135 of 136 CT-guided procedures (99.3%) (risk difference, -0.8 percentage points; 95% CI, -2.7 to 3.9), meeting the noninferiority criterion. There was no statistically significant difference in localization error between groups (median [IQR]: AR group, 3.0 [0.0 to 5.0]; CT group, 3.0 [2.0 to 6.0]). AR guidance was associated with lower radiation exposure (median [IQR], 456.50 [378.75 to 631.85] vs 1260.11 [1026.48 to 1544.53] mGy · cm; P < .001), lower preoperative pain (median [IQR] numeric rating scale, 0 [0-0] vs 5 [4-6]; P < .001), shorter puncture time (median [IQR], 0.63 [0.50 to 0.83] vs 6.50 [5.00 to 8.75] minutes; P < .001), and shorter localization-to-incision interval (median [IQR], 2.00 [1.50 to 2.00] vs 33.50 [18.00 to 63.00] minutes; P < .001). Pneumothorax occurred in 40 of 136 CT-guided cases (29.4%).

CONCLUSIONS AND RELEVANCE: In this randomized clinical trial, single-encounter AR-guided localization was noninferior to CT-guided localization for achieving successful sublobar resection and was associated with reduced radiation exposure, lower pain, shorter puncture time, and a shorter localization-to-incision interval, supporting its use as an alternative to CT-guided localization.

TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT06548451.

PMID:42418181 | DOI:10.1001/jamasurg.2026.2516