Publications

BACKGROUND: Academic medical centers (AMCs) provide the nation's most complex care, with no differences in performance between trainees and faculty for inpatient outcomes. Single-center analyses demonstrated low performance on ambulatory outcomes among residents vs. faculty.

OBJECTIVE: Determine whether resident-faculty ambulatory care performance disparities are a national problem, understand contributing factors present in AMCs.

DESIGN: Retrospective cohort study, survey-based study PARTICIPANTS: A total of 146,961 patients receiving primary care at five AMCs within resident-faculty primary care training practices during calendar year 2019. Resident clinic directors at each of the sites participated in the survey-based analysis.

MAIN MEASURES: The main exposure was whether the patients received primary care in a faculty-supervised resident vs. faculty-only cohort. Outcome measures included rates of colorectal and breast cancer screening and control of type 2 diabetes mellitus and hypertension between the resident and faculty cohorts. We also assessed the level of agreement with five components of high-functioning primary care as defined by the National Academies of Sciences in interviews with residency practice leadership.

KEY RESULTS: After adjustment for key differences in social complexity, we observed resident-faculty disparities across all five sites for all outcomes, with disparities in breast cancer screening from RR 0.69 (0.62-0.78)-0.71 (0.63-0.80); disparities in colorectal cancer screening from RR 0.77 (0.68-0.88) to 0.90 (0.86-0.93); disparities in control of type 2 diabetes mellitus from RR 0.82 (0.69-0.97) to 0.90 (0.86-0.93); and disparities in control of hypertension from RR 0.79 (0.68-0.91) to 0.87 (0.79-0.95). The magnitude of resident-faculty performance disparities may be related to the likelihood of disagreement with the five components of high-functioning primary care.

CONCLUSIONS: Residents performed lower than faculty on routine ambulatory quality measures. The magnitude and number of disparities may be related to disagreement on the presence of components of high-functioning primary care. These findings highlight the need for more robust infrastructural support in primary care settings to meet the needs of patients.

Type 2 diabetes mellitus (T2DM) affects cognition and resting-state functional connectivity (rsFC). Intranasal insulin (INI) has emerged as a potential treatment for T2DM-related cognitive decline. We aimed to evaluate the effect of INI treatment on rsFC with medio-prefrontal (mPFC) and left/right hippocampus (lHPC/rHPC), and their relationship with the cognition, hemoglobin A1c (HbA1c), and homeostatic model assessment of insulin resistance (HOMA-IR) and walking speed. An MRI sub-study of the MemAID trial was conducted, involving a 24-week treatment with either intranasal insulin or placebo. Blood oxygen level-dependent (BOLD) functional MRI (fMRI) images were acquired on eighteen DM subjects at baseline and eleven DM subjects (eight DM-INI patients and three DM-Placebo) at the end-of-treatment. Compared to DM-Placebo treated subjects, DM-INI patients showed increased mPFC-postcentral rsFC, lHPC-frontal rsFC, lHPC-postcentral rsFC, rHPC-frontal rsFC, and lHPC-mPFC rsFC (p < 0.05). The decreased HOMA-IR, which was observed in the MemAID trial, was associated with increased mPFC-basal ganglia rsFC (p < 0.05). This sub-study provides insights into potential mechanisms of INI effects on rsFC that require validation in a larger trial.

Remote blood pressure (BP) monitoring, or blood pressure measurement outside of a clinical setting, has been an evolving approach to monitor BP outside of a clinical setting, allowing for a better understanding of day-to-day fluctuations in BP. This technology at home allows for detection of instantaneous fluctuations in BP that could be predictive of cardiovascular disease events. It also holds potential for more accurate diagnosis of hypertension and improved titration of antihypertensive medications. Home BP monitoring has traditionally focused on cuffed devices, but new technologies based on cuffless, wearable devices are emerging. These have novel applications clinically for continuous and intermittent blood pressure measurement. Although there are validation protocols for cuff-based devices, these do not always apply to cuffless devices, and both types require unique assessments for accurate BP measurements. Nevertheless, remote BP monitoring, including evolving cuffless devices, represents an intriguing prospect for monitoring BP and characterizing changes in patients' BP overtime. However, the overall clinical importance and application of instantaneous BP measurements remains unknown. The purpose of this review is to describe the current state of remote BP monitoring and evolving technologies in this field.

BACKGROUND: Migraine is a major cause of disability and efficacious interventions are needed. In this mechanistic study, we investigate the combined, and potentially synergistic, effects of a multimodal intervention combining Mindfulness-Based Stress Reduction (MBSR) and transcutaneous auricular Vagal Nerve Stimulation (taVNS) for migraine.

METHODS: We utilize a modified double-blinded, placebo-controlled, 2 × 2 factorial randomized longitudinal design to assess the effects of an 8-week MBSR intervention with concomitant Respiratory-gated Auricular Vagal Afferent Nerve Stimulation (RAVANS) taVNS on migraine pathophysiology primary outcomes. We will enroll 150 patients with migraine (4-20 headache days/month). After a run-in month of daily diaries, we expect to randomly assign N = 96 participants to one of four treatment groups: (1) MBSR+RAVANS taVNS, (2) MBSR+Sham taVNS, (3) Nature Education Control (NEC) + RAVANS taVNS, or (4) NEC + Sham taVNS. Before and after intervention, participants have three in-person assessments (a 7 T MRI scan, an autonomic/sensory testing (AST) visit, and a 3 T PET-MRI scan). The primary outcomes for this study assess (1) central sensitization (brainstem/cortical response to trigeminal sensory afference), (2) autonomic dysfunction (High Frequency-Heart Rate Variability (HF-HRV) response to stressors), and (3) neuroinflammation (PET[11C]PBR28 signal).

RESULTS: Funded by NIH (P01AT009965), registered (NCT03592329). Final longitudinal outcomes will be collected by May 2025.

CONCLUSION: This mechanistic study is designed to investigate both independent and synergistic neurobiological effects of MBSR and RAVANS taVNS interventions on three distinct pathophysiological mechanisms of migraine. This research will elucidate the mechanistic and potentially synergistic effects of behavioral interventions (e.g., mindfulness) and device-based treatments (e.g., taVNS) for migraine.

BACKGROUND: Impostor phenomenon (IP) is defined as self-doubt among high-achieving individuals. Previous studies have shown a high prevalence of IP among resident physicians, which can negatively impact the learning environment of academic teaching hospitals.

OBJECTIVES: This study explores how medical team leaders can help resident physicians overcome IP.

METHODS: A survey was conducted from February to June 2024 among internal medicine (IM), general surgery, and obstetrics and gynecology residents at Beth Israel Deaconess Medical Center. Using pragmatic qualitative analysis, the study identified leadership strategies that help alleviate IP.

RESULTS: Out of 125 respondents (49% response rate), 70% were IM residents, 14% OB-GYN, and 16% general surgery residents. Higher PGY levels were associated with lower odds of frequent IP, with an odds ratio of 0.71 (95% confidence interval of 0.51-0.97). Gender and specialty were not significantly associated with higher IP frequency. Effective leadership strategies included normalizing IP, providing specific feedback, demonstrating trust, and fostering a safe space to discuss negative thoughts.

CONCLUSION: Team leaders can help with learners' IP by normalizing it, taking time to give specific and constructive feedback, empowering the learner through trust, and creating a safe space to discuss negative self-perceptions. Imposter phenomenon declines with increased experience throughout residency. Future work needs to explore how to effectively train all resident and faculty team leaders with these strategies and their impact on medical student and intern wellness, especially in high-risk specialties and training levels.

BACKGROUND: Orthostatic hypotension (OH) is associated with cardiovascular disease, particularly among older adults. While a standing transthoracic echocardiogram (TTE) could theoretically identify changes in cardiac output to diagnose cardiogenic OH, there are no established protocols for orthostatic TTEs and their feasibility is unknown.

METHODS AND RESULTS: We recruited 115 patients scheduled for elective outpatient TTE. Consenting participants, who were able to stand safely, underwent their scheduled recumbent TTE, followed by a standing TTE, performed within 1-2 minutes of standing. The focused TTE used the apical window to measure velocity time integral across the aortic valve to assess cardiac output. Blood pressure (BP) was measured in the supine and standing positions and patients were asked about symptoms of dizziness and lightheadedness. OH was defined as a change in standing minus supine systolic BP ≤-20 mm Hg or in diastolic BP of ≤-10 mm Hg. Of the 115 enrolled participants, 102 (89%) completed the standing echocardiogram protocol. Among those completing, mean age was 63.4 (SD, 14.8) years (38% were ≥ 70 years), 48% women, and 34% had a BMI ≥ 30 kg/m2. There were 21% with OH. Upon standing, systolic BP changed by -5.9 mm Hg (95% CI: -9.5, -2.2), diastolic BP by 2.4 mm Hg (-0.1, 4.8), and cardiac output by -0.4 L/min (95% CI: -0.7, -0.1). Change in cardiac output (per 1 L/min) was associated with a higher odds of systolic OH (OR: 1.60; 95% CI: 1.05, 2.42), but not diastolic OH (OR: 1.21; 95% CI: 0.63, 2.32).

CONCLUSIONS: Standing TTE is safe, well-tolerated, and feasible in the ambulatory setting. Moreover, TTE changes in cardiac output are associated with systolic OH. This clinical assessment shows promise for distinguishing OH etiologies and could inform further research on treatments to prevent OH.

OBJECTIVES: Guidelines recommend women consider their breast cancer risk and life expectancy when deciding on breast cancer screening (e.g., intervals, when to stop) and prevention medication. We previously developed a competing-risk model to predict 10-year breast cancer risk and non-breast cancer death in women > 55 years to support decision-making. Here, we aimed to develop a decision aid (DA) website incorporating our model's risk estimates.

METHODS: We designed the DA based on international standards using the free R package Shiny. We included a risk-assessment page, risk estimates, and decision support on breast cancer screening and prevention medications. We recruited national experts, Boston-area primary care practitioners (PCPs), and female patients > 55 years without breast cancer history to provide feedback on the DA via questionnaire or personal interview. We used thematic analysis to identify themes in participants' open-ended comments until reaching thematic saturation. Study questionnaires assessed DA helpfulness and ease-of-use.

RESULTS: Forty-five (53.6 %) of 84 eligible patients approached participated. Their mean age was 65.9 years (SD 7.9), 31 (68.9 %) were non-Hispanic White, and 31 (68.9 %) graduated college. Of 52 experts/PCPs contacted, 30 participated. Participants found the DA helpful (35/44 patients [79.5 %] and 28/29 [96.6 %] experts/PCPs) and easy-to-use (39/45 patients [86.7 %] and 28/29 PCPs/experts, [96.6 %]). They described the DA as "informative" and liked the "tailored-risk information." They suggested changes to simplify the DA and to better individualize the decision-support. We iteratively revised the website. We could not program some recommended changes using the free R application.

CONCLUSIONS: We developed an informative and easy-to-use breast cancer screening and prevention medication DA website (https://bcrisk55plus.shinyapps.io/risktool/) for women > 55 using free software. Next, we will program the website using HTML code and test its effects prospectively.

PRACTICE IMPLICATIONS: We anticipate that use of the DA will help women > 55 with breast cancer screening and prevention decisions.

PurposeDelirium is a common yet preventable complication of hospitalization, surgery and illness that is associated with poor outcomes. Older adults with Alzheimer's Disease and Related Dementias (ADRD) are especially vulnerable to delirium and experience greater delirium severity, yet no existing assessment tool is specifically designed to evaluate this vulnerable population. This study will validate two new delirium severity instruments, the Delirium Severity (DEL-S) rating for all older adults and the Delirium Severity Rating in ADRD (DEL-S-AD) for patients with dementia.Design/Setting and ParticipantsThe Better ASsessment of ILlness II (BASIL II) study is an innovative prospective cohort study that measures cognitive function, delirium, delirium severity, demographics, clinical and functional variables and clinical outcomes. Participants include older adults from 3 unique yet complementary clinical sites: medical inpatients, elective surgery inpatients, or skilled nursing facility residents.MethodsPerformance of DEL-S and DEL-S-AD items in older adults with cognition ranging from no impairment to moderate impairment will be determined. Analyses will include psychometric characteristics of DEL-S and DEL-S-AD items, harmonization of the two scales and validation against reference standard diagnoses.Conclusions and ImplicationsResults from this study will help accurately measure delirium severity, a critically important, graded outcome. The DEL-S-AD instrument holds broad applications in persons with and without ADRD to monitor delirium severity in clinical settings, and as an outcome measure in future clinical treatment trials and pathophysiologic studies. Ultimately, the DEL-S and DEL-S-AD have the potential to improve health care for the vulnerable, growing population of older adults with cognitive impairment worldwide.