Tag: statistics

JAMA Netw Open. 2026 Apr 1;9(4):e269673. doi: 10.1001/jamanetworkopen.2026.9673.

ABSTRACT

IMPORTANCE: Hypertrophic cardiomyopathy (HCM) is associated with an elevated risk of sudden cardiac death, often preceded by an out-of-hospital cardiac arrest (OHCA). However, population-based estimates of OHCA risk in patients with HCM are limited.

OBJECTIVE: To estimate the risk of OHCA in patients with HCM and identify characteristics associated with OHCA.

DESIGN, SETTING, AND PARTICIPANTS: This cohort study used multiple Danish registers during an observation period ranging from June 1, 2001, to December 31, 2022, and included a nested case-control study. All Danish residents aged 18 to 85 years during the study period constituted the source population. Patients with HCM were identified using codes from the International Statistical Classification of Diseases, Tenth Revision. The cohort included patients with a first-time HCM diagnosis and exposure-matched controls. In the nested case-control study, patients with HCM who experienced OHCA were risk-set matched with controls with HCM and no OHCA at the index time. Analyses were performed between September 1 and November 30, 2025.

EXPOSURE: First-time diagnosis of HCM.

MAIN OUTCOMES AND MEASURES: Time to OHCA from exposure or the matching date was the primary outcome. Risk estimates were determined using the Aalen-Johansen estimator. Association between covariates and OHCA was determined by conditional logistic regression.

RESULTS: The cohort included a total of 29 240 individuals: 5901 patients with HCM (median age, 65 [IQR, 54-75] years; 3277 male [55.5%]) and 23 339 matched controls (median age, 65 [IQR, 55-75] years; 12 982 male [55.6%]). In the group aged 61 to 85 years, the 10-year risk of OHCA was 4.3% (95% CI, 3.4%-5.1%) in patients and 3.3% (95% CI, 3.0%-3.7%) in controls. In the group aged 18 to 60 years, the 10-year risk was 2.8% (95% CI, 1.9%-3.7%) in patients and 1.5% (95% CI, 1.2%-1.8%) in controls. The nested case-control study included 250 cases with HCM and OHCA (167 male [66.8%]; median age, 68 [IQR, 59-76] years) and 1000 controls with HCM and no OHCA (668 male [66.8%]; median age, 68 [IQR, 59-76] years). Heart failure, both recent and longer term, was associated with an increased rate of OHCA (hazard ratio, 3.63 [95% CI, 1.55-8.50] and 2.82 [95% CI, 1.88-4.22], respectively).

CONCLUSIONS AND RELEVANCE: The findings of this cohort study suggest that HCM was associated with an increased risk of OHCA in people aged 18 to 85 years. The rate of OHCA was associated with heart failure, underscoring the need for improved risk stratification to optimize primary prevention.

PMID:42054027 | DOI:10.1001/jamanetworkopen.2026.9673

JAMA Netw Open. 2026 Apr 1;9(4):e269753. doi: 10.1001/jamanetworkopen.2026.9753.

ABSTRACT

IMPORTANCE: Syringe services programs (SSPs) are evidence-based interventions that reduce bloodborne infections and injection-related harms among people who inject drugs, yet access remains limited and geographically uneven across the US.

OBJECTIVE: To quantify the travel time, distance, and cost required to reach the nearest SSP from population-weighted census tracts nationwide and to examine differences by urbanicity, state, and SSP legality.

DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional geospatial study linked all known SSP locations as of August 2024 to the population-weighted centroids of census tracts in the 50 US states and the District of Columbia. Analyses were conducted between December 2024 and February 2026.

MAIN OUTCOMES AND MEASURES: Population-weighted mean and median driving time, distance, and cost to access the nearest SSP, stratified by National Center for Health Statistics urban-rural county category and SSP legal status. Costs were estimated using 2024 Internal Revenue Service (IRS) medical mileage deduction rates and 2022 state-specific gasoline prices.

RESULTS: In 1338 SSPs across 83 780 census tracts, the population-weighted mean 1-way driving time to the nearest SSP was 46.1 minutes (95% CI, 45.7-46.5 minutes) and the median was 23.3 minutes (IQR, 12.2-58.5 minutes). Altogether, 23.1% of the population lived more than 60 minutes from an SSP and 12.6% lived over 120 minutes away. The mean 1-way driving distance was 41.8 miles (95% CI, 41.3-42.2 miles). The mean 1-way driving cost was $8.77 (95% CI, $8.68-$8.86) using the 2024 IRS mileage rate and $6.91 (95% CI, $6.84-$6.98) using state mean gasoline prices in 2022. In states where SSPs were legal, mean driving time was 30.1 minutes (95% CI, 29.8-30.4 minutes) and mean cost by IRS mileage rates was $4.94 (IQR, $4.88-$5.00), compared with 110.7 minutes (95% CI, 109.6-111.8 minutes) and $24.19 (IQR, $23.92-$24.46) in states where SSPs were illegal.

CONCLUSIONS AND RELEVANCE: This cross-sectional study of travel burden to SSPs found substantial geographic and financial barriers to accessing SSPs across the US, particularly in nonmetropolitan areas. Targeting new SSPs to areas with the greatest travel burden could improve utilization and reduce drug-related morbidity.

PMID:42054025 | DOI:10.1001/jamanetworkopen.2026.9753

JAMA Netw Open. 2026 Apr 1;9(4):e269816. doi: 10.1001/jamanetworkopen.2026.9816.

ABSTRACT

IMPORTANCE: Approximately 10% of cancers are attributable to heritable germline variants, yet identification of individuals at risk remains suboptimal.

OBJECTIVE: To assess the feasibility of personal history and family health history (FHH) risk assessment technology via the electronic medical record (EMR) to enhance identification of patients at risk for a broad array of inherited cancer syndromes.

DESIGN, SETTING, AND PARTICIPANTS: This single-arm, nonrandomized clinical trial was completed from October 1, 2021, to September 1, 2023, with no follow-up period in unselected patients receiving care at Vanderbilt University Medical Center. Adult patients (aged ≥18 years) were invited through their EMR patient portals to complete an eligibility survey. Eligible participants completed the survey, were English speaking, and had no prior genetic counseling. The data analysis was performed between August 15 and November 7, 2025.

INTERVENTION: Electronic medical record-integrated risk assessment platform that collected self-reported personal history and FHH to assess risk for 24 hereditary cancer syndromes.

MAIN OUTCOMES AND MEASURES: The primary outcome was the completion rate of the risk assessment platform. Secondary outcomes included the percentage of newly identified participants meeting guideline criteria for genetic counseling and whether previsit FHH collection increased genetic counseling capacity by decreasing time spent in counseling.

RESULTS: A total of 1685 patients were consented to participate (mean [SD] age, 55.4 [15.1] years; 1217 female [72.2%]; 95 of Black or African American [5.6%] 1405 of White [83.4%], and 181 of other [multiracial, other, or unknown] [10.6%] race; 38 of Hispanic or Latino [2.3%], 1388 of non-Hispanic or Latino [82.4%], and 111 of unknown [6.6%] ethnicity). Among participants consented, 1483 (88.0%) were provided access to the risk assessment, 1106 (74.6%) started the assessment, 636 (57.5%) completed it, and 544 (49.1%) received a risk report. Younger age and unknown race and ethnicity were the only significant variables associated with completion (mean [SD] age, 53.5 [15.3] vs 56.9 [14.8] years for completers vs noncompleters, respectively; unknown race, 77 [14.2%] vs 43 [7.6%] for noncompleters; unknown ethnicity, 49 [9.0%] vs 20 [3.6%] for completers vs noncompleters, respectively). Among participants who completed the risk assessment, 155 (28.5%) met guideline criteria for genetic counseling, yet 74 (47.7%) were previously identified as at risk by billing codes. A total of 31 participants (20.0%) eligible for genetic counseling attended. Manual outreach efforts and counseling duration did not differ between risk assessment-assisted and usual care visits.

CONCLUSIONS AND RELEVANCE: In this nonrandomized clinical trial, almost one-third of the population met national genetic counseling criteria for an inherited cancer syndrome, highlighting a substantial gap in usual care identification. Integrating patient-facing FHH collection and assessment tools for primary care patients improves inherited cancer risk identification and highlights opportunities to further enhance both risk assessment processes and genetic counseling attendance.

TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT05079334.

PMID:42054024 | DOI:10.1001/jamanetworkopen.2026.9816

JAMA Netw Open. 2026 Apr 1;9(4):e269828. doi: 10.1001/jamanetworkopen.2026.9828.

ABSTRACT

IMPORTANCE: Studies have demonstrated lower odds of survival from out-of-hospital cardiac arrest (OHCA) during nighttime hours, but this has not been studied in North America since 2013, and it is unclear what factors might explain this survival difference.

OBJECTIVE: To identify whether OHCA survival during nighttime hours remains lower than during daytime hours using contemporary data and whether it can be explained by variable patient physiology or emergency care factors.

DESIGN, SETTING, AND PARTICIPANTS: This cohort study included adults (aged ≥18 years) with OHCA in the Cardiac Arrest Registry for Enhanced Survival from 2013 to 2024.

EXPOSURE: Daytime was defined as 7:00 am to 10:59 pm, and nighttime was defined as 11:00 pm to 6:59 am.

MAIN OUTCOME AND MEASURES: Primary outcomes were sustained return of spontaneous circulation (ROSC) and neurologically favorable survival (Cerebral Performance Category score of 2 or more). A multilevel mixed-effects logistic regression model with prehospital agency as a random effect and patient or treatment characteristics as fixed effects was used. A similar analysis of postresuscitation survival was performed among patients with sustained ROSC, adjusting for the time-to-cardiopulmonary resuscitation interval and defibrillation status. A mediation analysis was performed to identify whether the prehospital response interval mediates the association.

RESULTS: Of 1 151 845 patients in the registry, 874 415 were eligible and included in the analysis, and the median (IQR) age in the cohort was 64 (52-75) years with 557 515 males (63.8%) and 181 878 Black or African American patients (20.8%), 146 352 Hispanic or Latino patients (16.7%), and 447 646 White patients (51.2%). A minority of OHCA responses occurred at nighttime (241 967 [27.7%]), and the odds of sustained ROSC and neurologically favorable survival were lower at nighttime than daytime (sustained ROSC: 62 548 [25.8%] vs 193 486 [30.6%]; adjusted odds ratio [aOR], 0.85; 95% CI, 0.84-0.86; neurologically favorable survival: 16 234 [6.7%] vs 58 542 [9.3%]; aOR, 0.84; 95% CI, 0.82-0.86). Among those with sustained ROSC, the odds of postresuscitation survival at nighttime were also lower than daytime (aOR, 0.93; 95% CI, 0.90-0.95). The prehospital response interval partially mediated the nighttime survival disadvantage, with approximately 12.6% of the total effect mediated by the response interval.

CONCLUSIONS AND RELEVANCE: In this cohort study of OHCA, nighttime response was associated with lower adjusted odds of sustained ROSC, neurologically favorable survival, and postresuscitation survival. Emergency care factors accounted for only a portion of the decreased odds of survival at nighttime.

PMID:42054023 | DOI:10.1001/jamanetworkopen.2026.9828

JAMA. 2026 Apr 29. doi: 10.1001/jama.2026.5006. Online ahead of print.

ABSTRACT

IMPORTANCE: The US Department of Veterans Affairs (VA) Whole Health approach was congressionally mandated in 2016 for patients with chronic pain receiving care in VA hospitals, but no randomized clinical trials have tested its benefits.

OBJECTIVE: To evaluate the effectiveness of a whole health team intervention in VA patients with chronic pain compared with cognitive behavioral therapy and with usual care, and to evaluate the effectiveness of cognitive behavioral therapy compared with usual care in reducing long-term pain interference.

DESIGN, SETTING, AND PARTICIPANTS: This randomized clinical trial involving 6 VA health systems in the US enrolled participants between September 18, 2020, and January 19, 2024. Final follow-up occurred on January 27, 2025. Analyses took place between April 1, 2025, and February 3, 2026. Participants were patients with chronic pain receiving VA primary care.

INTERVENTIONS: Patients with chronic pain were randomized (11:11:2) to receive a whole health team intervention (n = 343), cognitive behavioral therapy for chronic pain delivered in group sessions (n = 339), or usual care (n = 82) for 12 months. The whole health team included a primary physician or nurse practitioner, a second clinician providing nonpharmacological or integrative pain care, and a coach. The team provided interdisciplinary, individualized care consistent with the VA Whole Health model to attain personal health goals aligned with patients’ personal values and life goals.

MAIN OUTCOMES AND MEASURES: The primary outcome was the Brief Pain Inventory interference (BPI-I) subscale score (range, 0-10 points; higher scores indicate worse interference from pain; minimal clinically important difference, 1.0) at 12 months.

RESULTS: Of 764 randomized patients (mean [SD] age, 60.5 [12.3] years; 66.5% were men), 632 (82.7%) completed 12-month follow-up. At 12 months, the whole health group had significantly improved pain interference scores (from 6.6 to 4.9) compared with the cognitive behavioral therapy (from 6.4 to 5.5) (mean difference, -0.58 [97% CI, -1.11 to -0.05]; P = .02) and usual care (from 6.4 to 5.7) (mean difference, -0.77 [99% CI, -1.40 to -0.15]; P = .002) groups. At 12 months, cognitive behavioral therapy did not improve pain interference scores significantly more than usual care (mean difference, -0.19 [99% CI, -0.89 to 0.50]; P = .46). The most common adverse event was suicidal ideation, which occurred in 15.9% of patients in the cognitive behavioral therapy group, 13.7% in the whole health team group, and 13.4% in the usual care group.

CONCLUSIONS AND RELEVANCE: These results support use of the whole health team approach to attain a statistically significant but small improvement in pain interference in VA patients with chronic pain.

TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04330365.

PMID:42054020 | DOI:10.1001/jama.2026.5006

Health Educ Res. 2026 Mar 31;41(3):cyag014. doi: 10.1093/her/cyag014.

ABSTRACT

This single-site, pilot-scale randomized controlled study intended to evaluate the effects of a self-determination theory-informed (D6 gamification model-based) gamified breastfeeding counselling program on breastfeeding self-efficacy, breastfeeding success, and breast-related problems in postpartum participants. A pretest-posttest randomized controlled trial was conducted with 60 pregnant individuals recruited from a single university-affiliated private hospital in Türkiye, using a pilot-scale parallel group design. Participants were assigned to experimental (n = 30) and control (n = 30) groups by block randomization that was performed by an independent statistician. Due to the behavioural nature of the intervention, participant blinding was not feasible; however, outcome analyses were conducted by a blinded biostatistician. The intervention group received a digitally delivered gamified breastfeeding counselling program from gestational week 35 until week 2 postpartum, while the control group received routine prenatal and postnatal care. Data were obtained for validated measures of breastfeeding self-efficacy, breastfeeding success, and breast-related problems. Descriptive and inferential statistical analyses were conducted with SPSS 28.0 software. At week 2 postpartum, the mean breastfeeding self-efficacy scale-short form scores were significantly higher in the gamified counselling group than the control group (63.6 ± 6.2 versus 54.3 ± 8.4, P < .001, Cohen’s d = 1.26). Breastfeeding performance also favoured the intervention group, with higher infant breastfeeding assessment tool scores (8.6 ± 1.1 versus 7.3 ± 1.4, P < .001) and LATCH breastfeeding assessment scores (9.3 ± 0.7 versus 8.4 ± 1.1, P = .002). Furthermore, breast fullness severity that was assessed using a dichotomous self-reported outcome (present/absent) checklist in which higher scores indicate more severe fullness, was lower in the intervention group than the control group (2.5 ± 1.1 versus 4.0 ± 1.2, P < .001). Gamified breastfeeding counselling was effective in enhancing breastfeeding self-efficacy and breastfeeding success and reduced common breast-related problems. These findings provide preliminary evidence supporting the feasibility and short-term benefits of integrating gamification-based strategies into breastfeeding education, warranting larger multicenter studies with extended follow-up.

PMID:42054016 | DOI:10.1093/her/cyag014

J Periodontol. 2026 Apr 29. doi: 10.1002/jper.70058. Online ahead of print.

ABSTRACT

BACKGROUND: The accurate assessment of infraosseous periodontal defects is crucial for effective diagnosis and treatment planning. Cone-beam computed tomography (CBCT) enables detailed imaging of these defects; however, to leverage their full potential, CBCT images must be reconstructed in 3 dimensions (3D). Manual and semi-automatic (SA) segmentation methods are time-consuming and prone to human error. This study aimed to evaluate the performance of a deep learning (DL) model in segmenting mandibular infraosseous periodontal defects on CBCT scans.

METHODS: A multi-stage Segmentation Residual Network (SegResNet)-based DL model was used to segment CBCT scans from patients with stages III to IV periodontitis. Linear and volumetric measurements of infraosseous defects from DL-generated 3D models were compared to those obtained using SA segmentation. The depth (INFRA), width (WIDTH), angle (ANGLE), and volume of 48 infraosseous defects were assessed on both DL and SA segmentations.

RESULTS: Measurements made on the DL and SA segmentations correlated strongly. The intraclass correlation coefficient (ICC) was 0.941 (p < 0.0001) for INFRA, 0.943 (p < 0.0001) for WIDTH, 0.889 (p < 0.0001) for ANGLE, and 0.948 (p < 0.0001) for defect volume. These results indicate high reliability of the DL model in capturing key characteristics of infraosseous periodontal defects.

CONCLUSIONS: These findings support the use of DL-based CBCT segmentation as a valuable tool for enhancing periodontal diagnosis. However, as this study was limited to mandibular defects, applicability to maxillary cases remains to be validated.

PMID:42054008 | DOI:10.1002/jper.70058

Clin Transplant. 2026 May;40(5):e70552. doi: 10.1111/ctr.70552.

ABSTRACT

BACKGROUND: Cytomegalovirus (CMV) infection remains one of the most prevalent and consequential post solid organ transplant (SOT) infections. Treatment is often challenging, especially when dealing with refractory and resistant CMV infections.

METHODS: We performed a retrospective multicenter cohort study of SOT recipients with clinically significant CMV infection (csCMVi) during 2010-2016. The primary outcome was early refractory CMV infection and secondary outcomes were drug resistance, CMV recurrence, and mortality. Analysis was done with Kaplan-Meier, univariable logistic regression analysis, and multivariable Cox regression.

RESULTS: We included 145 SOT recipients with csCMVi, majority were liver transplant (49%). Most common induction was an anti-IL-2 antibody (43.9%). The majority (n = 82; 56.5%) were CMV D+/R- mismatch and presented asymptomatic infection (50.3%). After the initial 3 weeks of antiviral therapy, 13 (8.9%) patients had probable refractory csCMVi; most of them (10 [76.9%]) were CMV D+/R- mismatch. Longer time after transplant had lower risk (OR 0.68; CI 0.48-0.95, p = 0.029) while lower absolute lymphocyte count (ALC) had a higher risk of early refractory csCMVi (OR 1.54; CI 1.01-2.44, p = 0.048). Drug-resistant csCMVi occurred in 7 patients (4.8%); a high initial CMV DNA level was associated with resistant csCMVi (OR 2.00; CI 1.08-3.93, p = 0.031). 25 patients (17.2%) experienced recurrent csCMVi within 6 months. 30 patients (20.7%) died; refractory, resistant or recurrent CMV infections were not associated with mortality.

CONCLUSION: Refractory csCMVi is associated with a low ALC and an earlier onset after transplant. Resistant csCMVi is associated with high initial CMV DNA levels. Recurrence of csCMVi is common and potentially associated with low ALC at the end of antiviral treatment.

PMID:42053990 | DOI:10.1111/ctr.70552

Reprod Fertil. 2026 Apr 29:RAF-25-0193. doi: 10.1530/RAF-25-0193. Online ahead of print.

ABSTRACT

ABSTRACT: High-risk fertility behavior is a leading contributor to adverse maternal and child health outcomes. This study assessed the prevalence and determinants of high-risk fertility behavior among reproductive-age women in sub-Saharan Africa. We conducted a secondary analysis of Demography and Health Survey data from eight sub-Saharan African countries with extremely high or very high maternal mortality. A weighted sample of 78,353 reproductive-age women who had given birth in the five years preceding the survey was included. A multilevel mixed-effects binary logistic regression model was used to identify individual- and community-level factors associated with high-risk fertility behavior, accounting for the hierarchical nature of the data. Statistical significance was determined using AOR with a 95% CI and a p-value ≤ 0.05. The overall prevalence of high-risk fertility behavior was 71.46% (95% CI: 71.14%, 71.77%)), with the highest prevalence observed in Chad (87.75%) and the lowest in Lesotho (40.49%). Key individual-level determinants included women’s and husbands’ education, religion, wealth status, child sex, marital status, mobile phone and internet use, antenatal care attendance, history of pregnancy termination, and contraceptive use. At the community level, low poverty was associated with a reduced likelihood of high-risk fertility behavior. The prevalence of high-risk fertility behavior remains high in countries with extremely high and very high maternal mortality countries, highlighting a need to address it through urgent and concerted interventions. Policymakers and planners should prioritize interventions targeting the key determinants high-risk fertility behavior to curb its occurrence and improve maternal and child health outcomes.

LAY SUMMARY: High-risk fertility behavior (HRFB) is defined as having children at very young or older ages, having many births, or spacing pregnancies too closely, which can lead to serious health problems for mothers and children. This study aimed to determine the magnitude of high-risk fertility behaviors and the factors that affect the behavior among women in eight sub-Saharan African countries with very high maternal mortalities. Using data from over 78,000 women, we analyzed both individual and community-level characteristics linked to HRFB. This study found that about 71% of women had HRFB. The highest rates were in Chad, and the lowest were in Lesotho. Factors such as low education, poverty, limited use of antenatal care, lack of contraception, and reduced access to mobile phones or the internet increased the likelihood of HRFB. Communities with lower poverty showed lower rates. These findings underscore the need for targeted policies and programs to reduce HRFB and improve maternal and child health.

PMID:42053982 | DOI:10.1530/RAF-25-0193

Can J Public Health. 2026 Mar;117(Suppl 1):125-135. doi: 10.17269/s41997-025-01118-1. Epub 2026 Apr 29.

ABSTRACT

SETTING: In France, participation rates in breast cancer screening have been decreasing, along with socio-territorial inequalities. To enhance women’s access to breast cancer screening, an interventional research project was implemented to assess the effectiveness, efficiency, and optimal modalities of a mobile mammography unit for women living remotely in Normandy.

INTERVENTION: The randomized cluster trial was directed towards rural women. Before deploying the mobile unit, an intervention theory was developed. The principles of action to reduce inequalities, the definition and standardization of interventions, and the link to behavior change theories to establish causal mechanisms were integrated into a single model. We aimed to produce new knowledge on these mechanisms and develop intervention evaluations.

OUTCOMES: Using the key function/implementation/context model, the key functions of the expected intervention were listed, linked to the behavior change technique and theoretical domain framework, and finally to the capability, opportunity, motivation-behavior model components. The mechanisms and levers that can improve access to breast cancer screening are also described. This approach also allowed the standardization of stakeholders’ implications and their corresponding actions. Concrete interventions implemented included scheduling appointments at the mobile unit and implementing a suite of measures to improve the information provided to women regarding breast cancer screening.

IMPLICATIONS: This theoretical framework should be compared with interventions carried out during the deployment of mobile units. Various elements interact dynamically with and alter originally planned interventions. This experiential feedback may inform decisions on the transferability of mobile mammography units to other contexts. TRIAL REGISTRATION : This study was registered at ClinicalTrials.gov (registration date: December 21, 2021; registration number: NCT05164874).

PMID:42053923 | DOI:10.17269/s41997-025-01118-1