Publications

INTRODUCTION: Chronic pain can lead to challenges in social functioning that extend into healthcare. The Mentalizing & InteRpersonal Recognition of Others' Relational States (MIRROR) intervention was developed to support patients' relational and communication skills in healthcare by targeting mentalizing (the ability to understand mental states of oneself and others). This paper describes MIRROR and reports preliminary findings regarding feasibility and acceptability across two pain samples.

METHODS: Eleven patients with chronic low back pain (cLBP, mean age 39.64 ± 16.37) and 12 patients with fibromyalgia (FM, mean age 38.83 ± 15.25) completed the four-session intervention. Questionnaires assessed session value and applicability, perceived benefit and generalization, and Perceived Efficacy in Patient-Physician Interactions (PEPPI).

RESULTS: Session ratings reflected moderate-to-high value and applicability (mean over 4 sessions: cLBP 1.22 ± 0.46, FM 1.45 ± 0.46; scale: -2 to 2), and perceived benefit and generalization (mean cLBP 0.88 ± 0.77, FM 0.71 ± 0.58; scale: -2 to 2). Exploratory pre-post changes in PEPPI scores indicated a medium effect observed in cLBP (Hedges' g = 0.52) and a small effect in FM (Hedges' g = 0.10). Open-ended feedback supported acceptability and feasibility.

CONCLUSIONS: MIRROR appears feasible and acceptable as an intervention engaging mentalizing methods for enhancing patients' ability to navigate clinical interactions. Further research should evaluate whether engaging mentalizing abilities improves subsequent healthcare communication and outcomes.

CLINICAL TRIAL REGISTRATION: www.clinicaltrials.gov identifier is NCT06157866.

INTRODUCTION: Since many hospitalized older adults have delirium, assessment of baseline cognitive function often requires proxy-based measures. While the 16-item Informant Questionnaire on Cognitive Decline in Elderly (IQCODE) specifies cutoff scores for mild cognitive impairment (MCI) and dementia, the 8-item Informant Interview to Differentiate Aging and Dementia (AD8) provides only a single cutoff for "cognitive impairment," limiting its usefulness and precision. Our aim was to develop a crosswalk between the IQCODE and AD8 to identify cutoff scores on the AD8 for MCI and dementia.

METHODS: The IQCODE and AD8 were administered to proxies of hospitalized older adults. We used two methods: equipercentile, which matches percentiles between IQCODE and AD8 score distributions, and item response theory (IRT), which matches estimated latent traits of the two measures, to create a crosswalk of equivalent scores and identify AD8 cutoff scores for MCI and dementia.

RESULTS: A total of 264 hospitalized older adults (mean age 79.5 years, 55% women) and their proxies were recruited. Equipercentile and IRT methods yielded a crosswalk linking AD8 scores from 0 to 8 with IQCODE scores ranging from 1.0 to 5.0. An AD8 score of 2, corresponding to an IQCODE score of 3.2, was identified as the cutoff for MCI, while an AD8 score of 4, corresponding to an IQCODE score of 3.5, was identified as the cutoff for dementia.

DISCUSSION: Our crosswalk equates AD8 and IQCODE scores and provides cutoff values for MCI and dementia for the AD8, enhancing its clinical utility in acute care. By establishing empirically derived thresholds, this study strengthens comparability across proxy-based cognitive measures and expands the AD8's usefulness for distinguishing MCI from dementia. In acute settings, where delirium and time constraints limit direct testing, the AD8 offers a brief, reliable option for measuring baseline cognition and supporting early recognition of cognitive decline.

BACKGROUND: Accurate home blood pressure (BP) monitoring depends on appropriate cuff sizing, but the prevalence and cost implications of extra-large cuff need among US adults with hypertension are unknown.

METHODS: Using pooled data from 2017-2023 National Health and Nutrition Examination Survey (NHANES) with survey weighting, we estimated the prevalence of having a mid-arm circumference >43cm among US adults with hypertension, overall and by race/ethnicity. We also categorized home BP monitors listed on the US Validated Device Listing as standard (accommodating arm circumferences from 22-43cm) or extra-large cuff compatible (accommodating arm circumferences >43cm).

RESULTS: Approximately 6.6% of US adults with hypertension (∼ 7.2 million individuals) had an arm circumference >43cm. Prevalence was highest among Non-Hispanic (NH) Black adults (11.4%) followed by Other Race/Multiracial (8.2%), NH White (6.2%), Hispanic (5.3%) and NH Asian adults (0.9%). Of the 51 validated devices, only 22 (43.1%) accommodated arm circumferences >43cm. The mean total cost of an extra-large cuff compatible system was 32.7% higher ($99.06 versus $74.70 for standard devices).

CONCLUSIONS: More than 7 million US adults with hypertension require an extra-large BP cuff; the substantially higher cost of extra-large cuff-compatible devices represents an important and underrecognized barrier to accurate home BP monitoring.

OBJECTIVE: Our lab previously showed in simulation that excluding the formal baseline from the eligibility window would reduce regression-to-the-mean (RTM), lower apparent placebo response, and improve antiseizure medication (ASM) trial efficiency. A recent software re-review revealed a reversal on the final point: excluding baseline worsened trial efficiency. We investigated this paradoxical finding further by comparing two otherwise identical designs that differed only in whether baseline contributed to eligibility.

METHODS: The calibrated seizure-diary simulator CHOCOLATES generated a shared pool of approximately 220,000 simulated candidates. In the Overlap design, the 3-month eligibility window included the 2-month formal baseline (3 prospective months total). In the Separate design, eligibility was determined during a 3-month qualification window; candidates meeting eligibility then completed a separate 2-month baseline (5 prospective months total). Eligibility thresholds were 3, 4, or 5 seizures/month. Placebo and proportional drug effects of 20%, 30%, and 40% were simulated. Endpoints were median percent change (MPC) and 50% responder rate (RR50). Empirical type I error was calibrated using 100,000 null trials per cell; sample size for 90% empirical power (N90) and prospective candidate-month burden were estimated.

RESULTS: Separate reduced baseline inflation (1.20 vs 1.60 seizures/month at the 4/month threshold), placebo MPC (-2.1% vs 6.7%), and placebo RR50 (12.1%vs 14.7%). However, Separate required more randomized participants in every scenario, increasing N90 by 5.7%-8.8% for MPC and 6.9%-17.9% for RR50. At the conventional 4/month threshold and 20% drug effect, RR50 required 620 randomized participants with Overlap versus 700 with Separate. Separate candidate-month burden was 1.32-1.45 times that of Overlap.

SIGNIFICANCE: Reducing RTM did not improve trial efficiency. The formal baseline both introduces RTM bias and verifies that randomized patients carry sufficient endpoint information; separating baseline from eligibility reduces the former but weakens the latter. In this simulation, the baseline-inclusive design was more efficient across every threshold, endpoint, and drug effect. Trial designers should evaluate eligibility and baseline rules as an integrated measurement system, not by apparent placebo response alone.

OBJECTIVES: Despite the dramatic growth in the number of clinical trials of meditation and/or mindfulness-based interventions (MMBIs), most trials focus on self-reported or psychological outcomes, less is known about the potential neuroplastic effects of MMBI practice and benefits for brain health. In this review, we aimed to map the extent and nature of existing research on this topic, identify subdomains, and determine the feasibility of conducting further systematic reviews.

METHODS: We conducted a bibliometric scoping review and summarized characteristics of randomized controlled trials (RCTs) with electroencephalography (EEG)-based measures for MMBIs, including publication year, country, participant characteristics, sample size, trial arms, intervention duration and components, EEG experimental design, and reported EEG-based outcomes.

RESULTS: From 3401 retrieved publications through a systematic search, we identified 142 eligible publications from 31 countries. More than half (54.6%) were published in the past five years. Ninety studies (63.4%) included healthy participants. Clinical conditions varied, but the majority included psychiatric/mental disorders, followed by pain or substance use, neurological disorders, sleep disturbances or insomnia, cancer/tumor, and age-related cognitive decline. Most studies focused on cognitive function/performance, memory/learning, executive function, attention/vigilance, sensory/perception, emotional/affective, or distress/stress. The two main types of EEG assessments were spectral analysis and measures from event-related potential.

CONCLUSIONS: Despite the large number of RCTs on MMBIs with EEG outcomes, our synthesis shows significant heterogeneity in study populations, research aims, experimental designs, performed tasks, and reported outcomes. Further systematic reviews and meta-analyses will require accumulation of additional original studies to allow a meaningful focus on specific topics with sufficient amount of evidence. Future research examining neuroplastic effects of MMBI practice utilizing objective physiological EEG-based measures are warranted and encouraged to advance the mind-body field.

BACKGROUND: Telehealth use surged during the COVID-19 pandemic, but utilization after the pandemic and whether differences in use by various sociodemographic and clinical factors have persisted are unknown.

OBJECTIVE: To assess changes in telehealth use among US adults from 2022 to 2024.

DESIGN AND PARTICIPANTS: This repeated cross-sectional study used nationally representative data from the 2022 and 2024 Health Information National Trends Survey (HINTS).

MAIN MEASURES: Self-reported telehealth use (any video or telephone visit in the past 12 months). Changes in the use were evaluated using logistic regression, adjusting for sociodemographic, clinical, and access-related variables and interactions with survey year.

KEY RESULTS: Among 11,386 respondents (mean [SD] age, 48.6 [17.8] years; 51.1% female), the unadjusted prevalence of telehealth use declined from 39.0% (95% CI [36.9%, 41.3%]) in 2022 to 34.9% (95% CI [32.1%, 37.9%]) in 2024, with a substantial decline among women. The proportion of visits conducted by video remained stable (71.1%, 95% CI [68.8%, 73.4%]), but increased considerably among uninsured individuals. Overall telehealth use was associated with age, internet use, higher income, and large-metro residence; among users, video use was additionally associated with Northeast residence and depression. Most associations did not differ by year, while gender differences in overall use and insurance differences in video use narrowed. Although approximately 20% reported technical problems, over 75% rated telehealth care as comparable to in-person care.

CONCLUSIONS: Self-reported telehealth use declined modestly after 2022, although video-based visits and perceived quality remained stable. Most of the previously recognized differences in telehealth use by sociodemographic and clinical factors persisted over time, but differences by gender and insurance status narrowed. Due to high-perceived quality, broad access to telehealth should continue with efforts to reduce structural and technological barriers.

Postoperative delirium is associated with both gut microbiota alterations and Tau phosphorylation; however, how these factors interact and jointly contribute to postoperative delirium remains poorly understood. This prospective observational cohort study screened 491 patients aged ≥65 years undergoing elective laminectomy or hip or knee replacement under general or spinal anesthesia at Massachusetts General Hospital (2016-2020). The study aimed to assess the correlation between plasma Tau protein levels, specific gut microbiota, and the gut microbiota-derived metabolite indole-3-propionic acid (IPA) in participants with and without postoperative delirium. Exclusion criteria included major neurological disease, smoking history, sensory impairment, and recent antibiotic use. Delirium was assessed 24-48 h postoperatively. Out of 491 screened participants, 139 had blood biomarker data, and 86 had gut microbiota data included in the final analysis. Ten percent of the participants experienced postoperative delirium. Co-occurrence network analysis demonstrated that microbial interactions differed between postoperative delirium and non-postoperative delirium groups. Significant associations among gut microbiota, IPA, and Tau biomarkers were observed only in postoperative delirium participants. Additionally, three machine learning classifiers distinguished postoperative delirium cases from non-postoperative delirium cases with Area Under the Curve values above 50%. The results suggest that plasma Tau may interact with gut microbiota, and this interaction is associated with postoperative delirium, suggesting the involvement of a gut-blood-brain axis in postoperative delirium vulnerability. These findings implicate a microbiota-Tau interaction that may represent both a potential pathogenic mechanism and a therapeutic target for postoperative delirium pending confirmative studies. Furthermore, machine learning classifiers utilizing microbiome-derived features demonstrate a potential in distinguishing patients with and without postoperative delirium.

BACKGROUND: There is limited data on the associations of (glycated hemoglobin A1C [HbA1C], fasting plasma glucose, and 2-hour postload glucose) and insulin resistance (fasting plasma insulin, insulin-to-glucose ratio, homeostasis model assessment of insulin resistance, and quantitative insulin sensitivity check index) markers with arterial stiffness.

METHODS: We included 6617 Framingham Heart Study participants (53.8% women; 6.9% diabetes, mean age: 48±14 years). Arterial stiffness measures included natural log (Ln)-transformed carotid-femoral pulse wave velocity, augmentation index (AIx), central pulse pressure, carotid-brachial pulse wave velocity, carotid-radial pulse wave velocity, and brachial pulse pressure. Estimates of associations were adjusted for several clinical characteristics.

RESULTS: Adjusted means of log (Ln)-transformed carotid-femoral pulse wave velocity, AIx, and carotid-brachial pulse wave velocity were increasingly abnormal with higher HbA1C (all P<0.05). Each 1% higher HbA1C was associated with elevated CFPWV (odds ratio [OR], 1.24 [95% CI, 1.11-1.39]) and lower AIx (OR, 0.86 [95% CI, 0.78-0.95]). Each 10-mg/dL higher fasting plasma glucose was associated with elevated CFPWV (OR, 1.09 [95% CI, 1.05-1.13]), but lower AIx (OR, 0.91 [95% CI, 0.87-0.94]). Each 10-mg/dL higher 2-hour postload glucose was associated with elevated CFPWV (OR, 1.04 [95% CI, 1.01-1.07]), central pulse pressure (OR, 1.04 [95% CI, 1.02-1.06]), brachial pulse pressure (OR, 1.04 [95% CI, 1.02-1.06]), but lower AIx (OR, 0.94 [95% CI, 0.91-0.96]). Higher fasting plasma insulin, insulin-to-glucose ratio, homeostasis model assessment of insulin resistance, and lower quantitative insulin sensitivity check index were associated with higher CFPWV and lower AIx (all P<0.05).

CONCLUSIONS: In community-dwelling individuals, worse glycemia and insulin sensitivity were associated with abnormal arterial stiffness.

Regression to the mean (RTM) can inflate apparent placebo response in epilepsy trials, but its mechanisms are often conflated. Using CHOCOLATES, we simulated 1,000,000 patients with 36 months of daily seizure counts and simulated placebo trials: 2-month baselines followed by 3-month test periods without treatment effects. Transient worsening (RTM type 1), stricter eligibility thresholds (RTM type 2), reduced sensitivity, and false alarms (RTM type 3) each increased RTM and apparent response. These findings show that placebo-arm improvement can arise from temporary illness, natural variability, measurement error, or mixtures thereof, informing epilepsy trial design and endpoint interpretation.