Publications

BACKGROUND: Exercise is important for people with multiple sclerosis (MS) to manage symptoms and improve quality of life. Tai chi and qigong (TCQ) are mind-body exercises shown to benefit physical, emotional, and cognitive health in many conditions, but research has been limited in people with MS. To understand potential benefits from regular TCQ practice and factors influencing feasibility, acceptability, and sustainability, we conducted a mixed-methods study through a survey and focus groups with people with MS who regularly practice TCQ.

METHODS: We conducted focus groups with people with MS from across the United States who regularly practice TCQ; the data from these groups were analyzed using reflexive thematic analysis. Participants also completed a brief survey that collected data on demographics, MS health history and symptoms, and TCQ practice (including opinions on content, dosage, and delivery).

RESULTS: Thirteen people with MS (85% female, 69% White) participated in the study. Reported TCQ benefits included physical (balance, strength), cognitive (memory), psychological (calming), and social (community building), with a dose-response gain over time. Challenges included learning and remembering movements, physical limitations (strength, endurance, fatigue), and transportation barriers. Adaptations specific to MS included tailoring TCQ content to meet individual needs and symptoms, appropriate pace, online delivery, and safety. Keys to sustainable practice included enjoyment, patience and self-compassion, viewing TCQ as medicine, and scheduling time for practice.

CONCLUSIONS: Results suggest people with MS who maintain a TCQ practice may experience physical, emotional, cognitive, and social benefits, especially when specific practice details and facilitators are met. Future studies might investigate how these factors influence sustainable practice.

BACKGROUND: Successful trial recruitment depends on balancing initial interest with participants' commitment and eligibility. It is uncertain how different motivational advertisement themes affect recruitment of interested and eligible trial participants.

METHODS: The GoFresh trials examined how healthy groceries affect blood pressure among Black adults from Boston healthy food priority areas. Using Facebook's "A/B testing" feature, users 18 years and older in eligible ZIP codes were randomly shown one of four digital advertisement themes-science volunteerism, study incentives, blood pressure reduction, or wellness in the Black community-between November 2023 and December 2024. We tracked Facebook and website analytics by theme. 'Interest' was defined as submission of an online interest form. 'Commitment' as visit no-show rates, and 'Eligibility' as qualification following the in-person visit. The 'number needed to screen' was calculated as 1 divided by the proportion of inquiries who were eligible.

RESULTS: Advertisements reached 603,418 Facebook users and generated 32,168 clicks, 264 inquiries, 73 scheduled visits, and 23 eligible participants. The community theme generated the highest inquiry engagement rate (54%) but lower commitment (8 no-shows) and the highest number needed to screen (17). The blood pressure theme had the lowest inquiry engagement rate (32%) but yielded the highest commitment (2 no-shows) and the lowest number needed to screen (8).

CONCLUSION: Beyond generating study interest, motivational themes may select for participants with varying degrees of commitment and eligibility, which could affect the cost-effectiveness of recruitment and long-term retention. These findings have important implications for timely and representative recruitment for cardiovascular trials.

REGISTRATION: URL: https://clinicaltrials.gov/; Unique Identifier: NCT05121337 &NCT05393232.

BACKGROUND: Clinical practice guidelines from the Endocrine Society recommend osteoporosis screening in high-risk men; however, the extent of implementation in clinical practice is unclear.

METHODS: We conducted a cross-sectional study using data from the National Ambulatory Medical Care Survey (NAMCS) from 2012 to 2019. We evaluated ordering patterns for dual-energy X-ray absorptiometry (DXA) during primary care visits among patients eligible for screening under the Endocrine Society Clinical Practice Guideline, based on guideline-concordant criteria operationalized using available NAMCS variables. We included men aged≥70 years and women aged≥65 years. Also, men aged 50-69 years and women aged 50-64 years with additional risk factors, such as body mass index<18.5 kg/m2, tobacco use, alcohol use disorder, or glucocorticoid therapy. We excluded visits among patients with osteoporosis. The trend in DXA screening was examined using multivariable, survey-weighted log-binomial regression models, and results are presented as relative risks (RR) with 95% confidence intervals (CI) and two-sided p-values.

RESULTS: We identified 4573 visits for eligible individuals. The median age was 72 years; 61% were women, 74% were non-Hispanic White, and 11% were non-Hispanic Black. The likelihood of DXA ordering was approximately 100 times less likely at visits among men suggested for screening (0.04%; 95% CI 0.00%-0.15%) than among women suggested for screening (5.1%; 95% CI 3.5%-7.1%). We observed no significant change in DXA ordering across survey years (p = 0.48). DXA ordering among women peaked at 6.9% in 2014-2016, while rates among men remained below 0.1%.

CONCLUSION: DXA ordering during U.S. primary care visits appears markedly low among men at risk for osteoporosis, representing a missed opportunity for early detection and fracture prevention.

BACKGROUND: Preoperative blood Tau phosphorylated at threonine 217 (Tau-PT217), a newly identified blood biomarker of Alzheimer's disease, is associated with postoperative delirium in patients. Anesthesia/surgery is also associated with postoperative increased blood Tau-PT217 amounts in patients. Moreover, in female aged mice, anesthesia/surgery increases Tau-PT217 in lungs, blood and brain tissues, leading to behavioral changes. However, whether these effects are sex-dependent remain largely undetermined.

METHODS: Eighteen-month-old female and male mice (C57BL/6J) underwent abdominal surgery under general anesthesia (1.4% isoflurane and 40% oxygen). Levels of Tau-PT217, inflammatory markers, and GSK3β activity were measured in lungs, blood, and brain tissues of aged mice using nanoneedle technology, Western blot, immunohistochemistry, RT-PCR and others. Postoperative delirium-like behavior was assessed using a battery of behavioral tests (buried food, open filed and Y maze). To explore causality, we performed orchiectomy and administered androgen receptor antagonist enzalutamide in aged male mice. Finally, testosterone was delivered via inhalation to aged female mice.

RESULTS: Anesthesia/surgery increased the amounts of Tau-PT217 in lungs (2.29±0.16 fold versus 1.15±0.71 fold, P<0.01), blood, and brain tissues of aged female, but not male, mice compared to control condition, leading to postoperative delirium-like behavior, as evidenced by increases in the composite Z score (3.74±1.46 versus 0.60±1.17, P<0.01), in the aged female, but not male, mice. Anesthesia/surgery elevated inflammatory markers and GSK3β activity in aged female mice, which exhibited lower baseline testosterone levels and androgen receptor expression in lungs compared to males. Both orchiectomy and enzalutamide treatment in male mice reduced testosterone levels and androgen receptor expression, leading to elevation of Tau-PT217 amounts and behavior changes following anesthesia/surgery. Conversely, testosterone inhalation in aged female mice mitigated the anesthesia/surgery-induced elevation of Tau-PT217 amounts and behavior changes.

CONCLUSIONS: Testosterone and androgen receptor signaling may contribute to the sex-dependent differences in Tau phosphorylation and postoperative behavior changes in aged mice.

Risk prediction model development has expanded rapidly, but few models have been translated into patient-facing tools that support informed decision-making. Existing breast cancer models provide no guidance on how to incorporate risk into decisions around screening or prevention medications, limiting their practical utility. To address this gap, we previously developed and validated a competing risk regression model that simultaneously predicts breast cancer and non-breast cancer death and then developed a web-based decision aid application that integrates this model with interactive, personalized information on screening and prevention medications. Using this application as a case study, we present a framework for developing an online decision aid using R Shiny. While prior Shiny tutorials have focused on simple applications or calculators, practical guidance for integrating risk prediction into multi-page, interactive decision support tools remains limited. In our tutorial, we describe key components of development, including application structure, user input collection, real-time calculation of individualized risk estimates, and presentation of results in a clear, interpretable format. We also demonstrate implementation of core Shiny functionalities, including reactive values for dynamic updates, data visualization techniques to contextualize risk estimates, and use of the observeEvent function to enable conditional display and navigation. Through this tutorial, we illustrate how risk calculators can be extended into comprehensive, dynamic and clinically useful tools that support informed decision-making.

Placebo analgesia demonstrates that belief and expectation can significantly alter pain, even without active treatment. Placebo analgesia can be induced through verbal suggestion, classical conditioning, or their combination, though the role of conditioned neural responses above and beyond effects of verbal instructions remains unclear. We conduct a systematic meta-analysis of individual participant data from 16 within-participant placebo neuroimaging studies (n = 409), employing univariate and multivariate analyses to identify shared and distinct mechanisms of placebo analgesia induced by suggestions alone versus suggestions combined with conditioning. Both techniques increase activity during pain in the dorsolateral prefrontal and inferior parietal cortices and decrease activation in the insula, putamen, and primary sensory areas. Adding conditioning enhances engagement of regions associated with context representation and pain modulation (e.g., dorsolateral/dorsomedial prefrontal cortices) and decreases in nociceptive regions (e.g., primary sensory and insular areas). Conditioning also strengthens the negative association between analgesia and nociceptive activity, as quantified by the Neurologic Pain Signature. Combining conditioning with instructions yields greater placebo analgesia, mediated by increased ventromedial prefrontal and dorsal caudate activity, alongside decreased sensory-nociceptive and cerebellar activity. These findings suggest the two strategies rely on partially distinct mechanisms in the brain.

BACKGROUND: Current clinical guidelines recommend home blood pressure monitoring (HBPM) to confirm hypertension diagnosis, guide therapy, and support long-term control. However, the optimal number of HBPM measurements needed for valid assessment is not established.

METHODS: At ARIC Visit 10 (2023), participants completed an eight-day HBPM protocol with morning and evening measurements and three readings per session. We evaluated the validity between the eight-day mean (reference) and streamlined protocols (fewer days, less than three readings per session, or only morning or evening measurements). In secondary analyses, we assessed the validity of these HBPM protocols relative to ambulatory BP.

RESULTS: Among 812 participants (median age 83 years, 24% Black adults, 40% male, 84% using anti-hypertensive medications), median BP varied by less than 3 mmHg across the eight-day protocol. The greatest improvement in HBPM validity occurred when extending the averaging window from one to two days. By three days, concordance correlation coefficients exceeded 0.95, and ≥97% of participants were within 10 mmHg of the reference for both systolic and diastolic BP. Averaging ≥2 readings per session, including both morning and evening measurements, yielded greater validity than a single reading or timepoint.

CONCLUSIONS: In this community-based cohort of older adults, HBPM provided stable BP estimates within three days (can be non-consecutive within an 8-day period) using morning and evening sessions with ≥2 readings each. While further studies are required to validate generalizability beyond this engaged cohort, these findings support shorter, less burdensome HBPM protocols in clinical guidelines for hypertension management in older adults.