Publications

IMPORTANCE: It is unclear whether and the extent to which subclinical myocardial injury or stress coexisting with prediabetes is associated with the risk of heart failure (HF).

OBJECTIVE: To evaluate the joint associations of prediabetes and subclinical myocardial injury or stress with incident HF risk.

DESIGN, SETTING, AND PARTICIPANTS: This post hoc prospective cohort study analyzed data from the Systolic Blood Pressure Intervention Trial (SPRINT). Two analytic samples were used: (1) adults with hypertension without diabetes or prior HF for the baseline biomarkers analysis and (2) participants with biomarker measurements at both baseline and 12 months for the longitudinal biomarkers' change. Prediabetes was defined as a fasting plasma glucose level of 100 to 125 mg/dL. Subclinical myocardial injury was defined as a high-sensitivity cardiac troponin I (hs-cTnI) level of 6 ng/L or higher in men and 4 ng/L or higher in women and subclinical myocardial stress defined as an N-terminal pro-B-type natriuretic peptide (NT-proBNP) level of 125 pg/mL or higher. A 25% or greater increase in any biomarker concentration from baseline to 12 months defined longitudinal change. Data were analyzed between January 1 and May 31, 2025.

MAIN OUTCOMES AND MEASURES: The primary outcome was adjudicated incident HF. Cox proportional hazards models were used to estimate hazard ratios (HRs) for HF across joint categories of prediabetes and biomarker elevation.

RESULTS: Of 8234 participants (mean [SD] age, 68 [9] years; 37.1% women), 3271 (39.7%) had prediabetes, 2942 (35.7%) had subclinical myocardial injury, and 3593 (43.6%) had subclinical myocardial stress. Over a median follow-up of 3.2 years (IQR, 2.8-3.8 years), 122 participants developed HF. Compared with normoglycemia and no myocardial injury, those with both prediabetes and injury had the highest HF risk (HR, 4.20; 95% CI, 2.31-7.63); similar findings were observed for myocardial stress (HR, 5.20; 95% CI, 2.52-10.70). In the longitudinal analysis (median follow-up, 2.3 years [IQR, 1.9-2-8 years]), 7449 participants with both prediabetes and a 25% or greater increase in hs-cTnI or NT-proBNP level had the highest risk of HF (for hs-cTnI: HR, 3.05; 95% CI, 1.58-5.88; for NT-proBNP: HR, 2.39; 95% CI, 1.28-4.46).

CONCLUSIONS AND RELEVANCE: These findings suggest that among adults with hypertension, prediabetes in combination with subclinical myocardial injury or stress is associated with a significantly elevated risk for HF. These findings support the integration of glycemic status and cardiac biomarkers profiling to improve HF risk stratification and guide prevention.

BACKGROUND: Suboptimal blood pressure (BP) control remains a major cardiovascular disease risk factor. Whether genetically predicted BP independently predicts long-term BP control is unknown. We examined the associations of BP polygenic scores (PGSs) with long-term BP control and treatment-resistant hypertension.

METHODS: We identified 22 456 Mass General Brigham Biobank participants with hypertension. Longitudinal BP control was defined as the percentage of time above-target systolic BP (SBP) ≥130 mm Hg or diastolic BP (DBP) ≥80 mm Hg over 5 years. Using multivariable regression, we assessed the associations of BP PGS with duration above-target BP and lifetime treatment-resistant hypertension incidence. Incremental prognostic utility of BP PGSs was assessed based on the discrimination C-index, Brier score, and net reclassification index. Validation was performed in the population-based UK Biobank cohort using the SBP/DBP ≥140/90 mm Hg threshold.

RESULTS: Among 10 853 (48.3%) were female, the mean SBP/DBP (SD) at index date was 132 (18)/75 (11) mm Hg, and 4126 (18.4%) developed treatment-resistant hypertension over lifetime. In reference to the low (<20th percentile) PGS group, the high (≥80th percentile) BP PGS was associated with 8.01 (95% CI, 6.68%-9.34%) longer duration with above-target SBP and 6.19 (95% CI, 5.05%-7.33%) with high DBP. Each high SBP and DBP PGS conferred 2.36 (95% CI, 2.07-2.68) and 1.75 (95% CI, 1.55-1.99)-fold higher odds of treatment-resistant hypertension. Adding BP PGSs to traditional risk factors improved treatment-resistant hypertension prediction from C-index (95% CI), 0.74 (0.73-0.75) to 0.78 (0.77-0.79). BP PGSs consistently predicted longitudinal BP management to a comparable extent in the UK Biobank.

CONCLUSIONS: Harnessing BP PGSs may inform anticipated trends in BP control to warrant vigilant monitoring and augment prioritization of intensive therapy.

BACKGROUND: Higher relative risk for cardiovascular disease (CVD) events at lower blood pressure (BP) thresholds in female versus male adults suggest that hypertension thresholds should be sex-specific.

METHODS: We used the ARIC study (Atherosclerosis Risk in Communities) visit 1 (1987-1989) to compare the BP distribution, estimated risk (via the 10-year Predicting Risk of Cardiovascular Disease Events score), absolute risk, and relative risk of CVD according to BP thresholds, stratified by sex and hypertension treatment status, in participants without prior CVD.

RESULTS: Of 13 418 participants (56% women, mean age [54±5.7 years]), 25% were treated for hypertension. Males had higher average 10-year CVD risk scores regardless of treatment. The distribution of BP and prevalence of CVD risk factors was similar for male and female adults. Incidence rates (per 10 000 person-years) comparing a systolic BP threshold of ≥140 versus <140 mm Hg for coronary heart disease were 30.9 and 12.0 among untreated male and female adults (P=0.07) and 27.4 versus 16.5 among treated male and female adults (P=0.63). HRs comparing a systolic BP threshold of ≥140 versus <140 mm Hg for coronary heart disease were 1.49 and 1.72 among untreated male and female adults (P=0.16) and 1.30 versus 1.40 among treated male and female adults (P=0.93).

CONCLUSIONS: In this middle-aged population, there were no consistent differences in BP distribution, risk factor burden, absolute risk, or relative risk of CVD between male and female adults. These findings do not support a sex-specific threshold for hypertension.

Hospitalist-focused training (electives, rotations, pathways, and tracks) evolved to address gaps in residency training pertinent to Hospital Medicine (HM). The Immersion in Hospital Medicine Elective (IHME) at Beth Israel Deaconess Medical Center immerses residents in curricular elements fundamental to HM, particularly clinical operations and healthcare economics. We surveyed IHME participants to evaluate the curriculum and characterize its impact on participants' professional development. Throughout the IHME's 20-year course, 120 residents participated, and 76 (63%) completed our survey. The majority practice HM (45, 63%) and viewed the IHME as valuable to their career preparation (36, 63%). The IHME bridged important gaps in medical knowledge and clinical skills development, such as the business of medicine, clinical operations, and creating a clinical staffing model. Most participants (59, 78%) attained key leadership positions, especially in medical education and clinical operations. Our study bolsters evidence that hospitalist-focused training in residency effectively prepares residents for adult HM practice.

PURPOSE: Orthostatic intolerance is a category of disorders characterized by inadequate hemodynamic compensation upon standing. In this study, we developed a portable, active abdominal compression binder intended for individuals with orthostatic intolerance. We present proof-of-concept evidence in healthy volunteers demonstrating the binder's ability to provide consistent abdominal compression, reduce tachycardic response upon standing, and maintain user comfort.

METHODS: We designed and fabricated a novel active binder that applies motor-driven abdominal compression upon the detection of standing. Twenty healthy volunteers (ages 18-50 years) completed three randomized supine-to-standing trials: no binder, a commercial passive binder, and the novel active binder. Throughout each trial, compression pressure, heart rate, and respiration were continuously monitored and comfort was assessed via post-trial Likert-scale survey.

RESULTS: The active binder achieved a higher mean compression pressure (≈ 11 mmHg) with significantly lower intersubject variability (standard deviation (SD) ≈ 1 mmHg) than the passive binder (mean ≈ 8 mmHg; SD ≈ 3 mmHg). Active compression reduced the standing heart rate by 4.4 bpm compared to control (p < 0.05) vs. a 1 bpm reduction with the passive binder (p > 0.05). Neither the active nor the passive abdominal binders impeded respiration. Survey responses demonstrated that the active binder was at least as comfortable as the passive and was rated easier to don.

CONCLUSION: These findings suggest that active abdominal compression may serve as a more efficacious, consistent, and user-friendly alternative to passive binders for mitigating orthostatic intolerance.

CLINICAL TRIAL NUMBER: Not applicable.

Vulvodynia, vulvar pain of unknown etiology, lasting 3 months or longer, affects 7% of American women, and has no consistently effective treatment. We aimed to test the efficacy of acupuncture on vulvar pain and dyspareunia and explore the duration of the effect in a double-blind randomized controlled trial of acupuncture for vulvodynia. 89 women, 19-62 years old (mean 30.2 ± 8.3), 70% White, 20% Hispanic; 91% completed a 13-needle, 10-session standardized acupuncture protocol using double-blind acupuncture needles. Average Pain Intensity of vulvar pain (API, 0-10 scale) and dyspareunia (Female Sexual Function Index) were measured at baseline and after the 10th treatment. Participants with a clinically important post-treatment improvement reported weekly Tampon Test scores (0-10), a measure of provoked vulvar pain, until they returned to baseline. Percentage of responders was similar: acupuncture 58%, placebo 57%; no significant differences were found between acupuncture and placebo groups on API or dyspareunia upon completion of treatments. Responders showed a consistently higher rate of return to baseline pain during the 12-week post-treatment follow-up in the placebo group compared to the acupuncture group (hazard ratio: 2.72, 95% CI: 1.13-6.54). Effects of acupuncture on vulvodynia may have been underestimated because of the strong placebo response from the skin-touch placebo needles. Among responders, the relatively large placebo effect did not persist for as many participants as the therapeutic effect of penetrating acupuncture during the 12-week follow up. Findings indicate investigations into the effects among acupuncture responders and non-responders are warranted. Findings also merit larger, pragmatic trials. PERSPECTIVE: Double-blind RCT of acupuncture for vulvodynia tested vulvar pain and dyspareunia and explored the duration of effect. Penetrating acupuncture and skin-touch placebo needle groups had pain reduction, not significantly different between groups. Pain reduction lasted longer for significantly more responders in the penetrating acupuncture vs. skin-touch placebo groups.

INTRODUCTION: Women ≥70 years with low-risk breast cancer face nuanced therapy decisions. Using qualitative analysis, we aimed to determine how oncologists and patients integrate geriatric considerations into complex treatment conversations.

MATERIALS AND METHODS: We recruited women aged ≥70, newly diagnosed with clinical T1-2N0 hormone receptor-positive/HER2-negative disease between October 2020 and March 2023 from a large cancer center and audio-recorded and transcribed their consults with surgical, medical, and radiation oncologists. We identified geriatric issues included in conversational content and the dynamics of patient/oncologist communication. Data collection and analysis were simultaneously performed. We also assessed participant decision-making preferences, frailty, and life expectancy.

RESULTS: Of 48 eligible patients approached, 27 (56 %) participated with eight surgical oncologists, 17 with 11 medical oncologists, and four with three radiation oncologists (n = 48 consultations recorded). Fourteen patients (48 %) were ≥ 75 years, 23 were non-Hispanic White (76 %). Patients preferred to share (n = 15, 58 %) or make their own treatment decisions (n = 10, 39 %), rather than defer to the oncologist. Oncologists presented an explicit treatment choice in 16 conversations (35 %). Chronological age was discussed in 27 (56 %) conversations, comorbidities in 44 (92 %), and multimorbidity in two (4 %). Other geriatric considerations were discussed in the minority of conversations [physiologic age: 20 (42 %); function: 20 (42 %); quality-of-life: 5 (10 %); life expectancy: 5 (10 %); polypharmacy: 2 (4 %)].

DISCUSSION: Despite numerous treatment options, oncologists neither commonly offer older women with low-risk breast cancer explicit treatment choices, nor discuss geriatric issues besides comorbidity. Training oncologists in communication around geriatric issues may lead to more person-centered breast cancer care.

BackgroundMessaging strategies hold promise to reduce breast cancer overscreening. However, it is not known whether they may have differential effects among medical maximizers who prefer to take action about their health versus medical minimizers who prefer to wait and see.MethodsIn a randomized controlled survey experiment that included 2 sequential surveys with 3,041 women aged 65+ y from a US population-based online panel, we randomized participants to 1) no messages, 2) single exposure to a screening cessation message, or 3) 2 exposures over time to the screening cessation message. We assessed support for stopping screening in a hypothetical patient and intention to stop screening oneself on 7-point scales, where higher values indicated stronger support and intentions to stop screening. We conducted stratified analyses by medical-maximizing preference and moderation analysis.ResultsOf the women, 40.7% (n = 1,238) were medical maximizers; they had lower support and intention for screening cessation in all groups compared with the medical minimizers. Two message exposures increased support for screening cessation among medical maximizers, with a mean score of 3.68 (95% confidence interval [CI] 3.51-3.85) compared with no message (mean score 2.20, 95% CI 2.00-2.39, P < 0.001). A similar pattern was seen for screening intention. Linear regression models showed no differential messaging effect by medical-maximizing preference.ConclusionsMedical maximizers, although less likely to support screening cessation, were nonetheless responsive to messaging strategies designed to reduce breast cancer overscreening.HighlightsIt is not known if a message on rationales for stopping breast cancer screening would have differential effects among medical maximizers who prefer to take action when it comes to their health versus medical minimizers who prefer to wait and see.In a 2-wave randomized controlled survey experiment with 3,041 older women, we found that medical maximizers, although less likely to support screening cessation compared with medical minimizers, were nonetheless responsive to the messaging intervention, and the magnitude of the intervention effect was similar between maximizers and minimizers.Medical maximizers reported higher levels of worry and annoyance after reading the message compared with the minimizers, but the absolute levels of worry and annoyance were low.Our findings suggest that messaging can be a useful tool for reducing overscreening even in a highly reluctant population.