Publications

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.

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.

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.

BACKGROUND: On average, Black adults compared to White adults have higher ambulatory blood pressure (ABP), particularly during sleep.

METHODS: Participants were randomly assigned to eat a control diet or the DASH diet (n = 335 with ABP, 58% self-reported Black). On their assigned diet, participants had three, randomly ordered, 30-day feeding periods with different sodium levels (low, intermediate, and high). ABP was obtained at the end of each period.

RESULTS: Compared to the control diet with high sodium (reference), reducing sodium and consuming the DASH diet, alone or combined, significantly lowered 24-hour, awake, and asleep systolic and diastolic ABP in Black and Non-Black participants. The DASH diet with low sodium reduced mean (95%CI) awake SBP by 9.0mmHg (6.4, 11.7) in Black participants and 7.5mmHg (4.5, 10.6) in Non-Black participants, and mean asleep SBP by 8.0mmHg (4.8, 11.2) in Black participants and 7.4mmHg (3.9,11.0) in Non-Black participants in comparison to the reference (each P < .05). Despite reductions in asleep ABP from the DASH diet and sodium reduction, significant differences by race persisted in achieved ABP, consistently so for asleep ABP. Mean±SE achieved levels of asleep SBP on the control diet with high sodium were 124.1 ± 0.6mmHg in Black participants and 120.2 ± 0.7mmHg in Non-Black participants (P < .005), while on the DASH diet with low sodium, achieved levels were 115.2 ± 0.5mmHg in Black participants and 112.5 ± 0.7mmHg in Non-Black participants (P < .005).

CONCLUSIONS: Despite clinically relevant reductions in ABP from sodium reduction and the DASH diet in both Black and Non-Black participants, racial differences in achieved levels of asleep ABP persisted.

Tools that help patients to digitally manage their health and health care have become increasingly important in recent years. The patient portal is the most well-established and widely used digital health tool through which patients may access their electronic medical record. Organizational efforts to promote awareness and use of the patient portal have primarily been directed at patients, yet millions of Americans with complex and costly health needs and disabilities manage their health with one or more care partners from among their family and friends. The presence and capacity of care partners can have profound effects on care quality and resource use, but their involvement is not well supported in care delivery. Care partners have been generally excluded from digital health initiatives and are often unable to access the information they need to coordinate or execute the patient's care plan. In this article, the authors take stock of the current landscape of care partner engagement through the patient portal, given its widespread availability and use. They describe the launch of the Coalition for Care Partners to stimulate collaborative initiatives to advance research, policy, and practice in this arena, and present an agenda to advance the field.

BACKGROUND: Left ventricular outflow tract obstruction is a major contributor to morbidity in hypertrophic cardiomyopathy and an established therapeutic target. However, the risk factors driving progression to symptomatic heart failure in asymptomatic patients with obstructive hypertrophic cardiomyopathy remain incompletely understood.

METHODS: We retrospectively identified 341 consecutive asymptomatic patients with obstructive hypertrophic cardiomyopathy (New York Heart Association class I, left ventricular ejection fraction >50%, left ventricular outflow tract gradient ≥30 mm Hg) across 4 centers between 2003 and 2023 (mean±SD age, 48±17 years; 78% men). All underwent transthoracic echocardiography and cardiovascular magnetic resonance. A combined adverse end point included progression to New York Heart Association class II or greater or development of systolic dysfunction (left ventricular ejection fraction <50%). Univariate and multivariable Cox regression analyses were performed.

RESULTS: Over 4.4 (range, 2.4-7.0) years, 98 patients (29%) experienced New York Heart Association progression (6.6%/year). Of these patients, 34 (35%) underwent septal reduction therapy, 4 (4%) developed end-stage heart failure without intervention, and 2 (2%) developed left ventricular ejection fraction <50%. Independent multivariable predictors of the adverse end point were impaired right ventricular stroke volume index, female sex, and prior atrial fibrillation. Patients with progression had lower right ventricular stroke volume index (37±12 versus 42±11 mL/m2; P=0.004; hazard ratio, 1.16 per 5-mL/m2 decrease), without significant age interaction (P=0.8). Those in the lowest right ventricular stroke volume index quartile (<34 mL/m2) had 2.5-fold higher progression risk than those in the highest quartile (>49 mL/m2).

CONCLUSIONS: Among asymptomatic patients with obstructive hypertrophic cardiomyopathy in a large longitudinal cohort, approximately one-third developed limiting symptoms over 5 years. Impaired right ventricular stroke volume index was a novel, independent predictor of future heart failure and may help identify high-risk patients, with implications for management.